Healthcare Provider Details

I. General information

NPI: 1922637586
Provider Name (Legal Business Name): CHRISTIAN MARTIN BOUDREAUX PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2020
Last Update Date: 11/05/2025
Certification Date: 11/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 BROADWAY STE R100
SAN ANTONIO TX
78209-5765
US

IV. Provider business mailing address

5500 BROADWAY STE R100
SAN ANTONIO TX
78209-5765
US

V. Phone/Fax

Practice location:
  • Phone: 210-802-0085
  • Fax: 210-775-0082
Mailing address:
  • Phone: 210-802-0085
  • Fax: 210-775-0082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA18113
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: