Provider Demographics
NPI:1487649091
Name:BOUDREAUX, STACI SIMON (PA-C)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:SIMON
Last Name:BOUDREAUX
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1869
Mailing Address - Street 2:
Mailing Address - City:FLETCHER
Mailing Address - State:NC
Mailing Address - Zip Code:28732-1869
Mailing Address - Country:US
Mailing Address - Phone:828-299-5515
Mailing Address - Fax:828-701-0626
Practice Address - Street 1:333 GASHES CREEK RD STE 111
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28803-9405
Practice Address - Country:US
Practice Address - Phone:828-299-5515
Practice Address - Fax:828-701-0626
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPAA10607 RX363A00000X
NC0010-10929363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1026867Medicaid
P00433996Medicare PIN
LA1026867Medicaid
LA57460P903Medicare PIN
LA5W776P598Medicare ID - Type Unspecified
LA57460PC57Medicare PIN