Basic Information
| Provider Information | |||||||||
| NPI: | 1417679572 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOUDREAUX | ||||||||
| FirstName: | AMBER | ||||||||
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| OtherLastName: | SERRETT | ||||||||
| OtherFirstName: | AMBER | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3817 ROBERTS BLVD | ||||||||
| Address2: | |||||||||
| City: | BAYTOWN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775218127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2814756238 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6720 BERTNER AVE | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770302604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3127248477 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2022 | ||||||||
| LastUpdateDate: | 09/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.