Healthcare Provider Details

I. General information

NPI: 1386864726
Provider Name (Legal Business Name): CARRIE BOURGET PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36800 N SIDEWINDER RD STE A-4
CAREFREE AZ
85377
US

IV. Provider business mailing address

PO BOX 5848
CAREFREE AZ
85377-5848
US

V. Phone/Fax

Practice location:
  • Phone: 480-595-0431
  • Fax: 480-595-2322
Mailing address:
  • Phone: 480-595-0431
  • Fax: 480-595-2322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberAZ2726
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: