MEDICARE: PETER BOURQUE NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	363LP2300X	Primary Care Nurse Practitioner
2	207QA0505X	Adult Medicine Physician
3	363LG0600X	Gerontology Nurse Practitioner
4	363LA2200X	Adult Health Nurse Practitioner
5	390200000X	Student in an Organized Health Care Education/Training Program
6	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1629810585
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PETER BOURQUE NP

Provider Business Mailing Address
First Line	:	3092 BAYHAVEN DR
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29579-1821
Country	:	US
Telephone Number	:	631-213-1770
Fax Number	:	631-315-8042

Provider Business Practice Location Address
First Line	:	1650 SYCAMORE AVE
Second Line	:
City	:	BOHEMIA
State	:	NY
Zip	:	11716-1738
Country	:	US
Telephone Number	:	631-213-1770
Fax Number	:	631-315-8042

Authorized Official
Title or Position	:	FOUNDER & CLINICAL DIRECTOR
Name	:	PETER RALPH BOURQUE JR.
Credential	:	MS, APRN, PMHNP-BC
Telephone Number	:	631-213-1770

Provider Enumeration Date	:	06/11/2024
Last Update Date	:	01/15/2026

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