MEDICARE: NICHOLAS BOUDREAU CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	9385003	FL
2	367500000X	Certified Registered Nurse Anesthetist	11019743	FL
3	367500000X	Certified Registered Nurse Anesthetist	APRN11019743	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	B360633910020	OTHER	FL	DRIVERS LICENSE

General Provider Information

NPI Number	:	1609497346
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS BOUDREAU CRNA

Provider Business Mailing Address
First Line	:	104 FOREST CIR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32803-6248
Country	:	US
Telephone Number	:	954-649-6279
Fax Number	:

Provider Business Practice Location Address
First Line	:	104 FOREST CIR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32803-6248
Country	:	US
Telephone Number	:	954-649-6279
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/05/2020
Last Update Date	:	07/13/2022

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