Healthcare Provider Details

I. General information

NPI: 1053223495
Provider Name (Legal Business Name): AIDAN L BOURBONNAIS PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 NORTH ST
HYANNIS MA
02601-3825
US

IV. Provider business mailing address

130 NORTH ST
HYANNIS MA
02601-3825
US

V. Phone/Fax

Practice location:
  • Phone: 508-775-8282
  • Fax:
Mailing address:
  • Phone: 508-775-8282
  • Fax: 508-775-8280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: