MEDICARE: GABRIELLE LUCIA BOURDEAU

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

General Provider Information

NPI Number	:	1467385245
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GABRIELLE LUCIA BOURDEAU

Provider Business Mailing Address
First Line	:	200 E 16TH ST APT 2C
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10003-3708
Country	:	US
Telephone Number	:	203-231-9464
Fax Number	:

Provider Business Practice Location Address
First Line	:	130 E 77TH ST FL 2
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10075-1851
Country	:	US
Telephone Number	:	212-434-2585
Fax Number	:

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

Provider Enumeration Date	:	06/03/2026
Last Update Date	:	06/03/2026

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Directions to “ GABRIELLE LUCIA BOURDEAU ” Practice Location

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