MEDICARE: MRS. MELISSA BETH BOUDREAUX PA-C

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	363A00000X	Physician Assistant	PA9102893	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164490116
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MELISSA BETH BOUDREAUX PA-C

Provider Business Mailing Address
First Line	:	PO BOX 863407
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32886-3407
Country	:	US
Telephone Number	:	941-917-2600
Fax Number	:	941-917-7884

Provider Business Practice Location Address
First Line	:	1040 RIVER HERITAGE BLVD
Second Line	:	SUITE 204
City	:	BRADENTON
State	:	FL
Zip	:	34212-6348
Country	:	US
Telephone Number	:	941-917-7100
Fax Number	:	941-917-7142

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

Provider Enumeration Date	:	03/08/2006
Last Update Date	:	05/15/2018

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Directions to “ MRS. MELISSA BETH BOUDREAUX PA-C” Practice Location

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