Healthcare Provider Details

I. General information

NPI: 1205823036
Provider Name (Legal Business Name): CHERYL R BOURGAULT PA C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 03/27/2023
Certification Date: 03/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 S GARDEN WAY SUITE 210
EUGENE OR
97401-8173
US

IV. Provider business mailing address

360 S GARDEN WAY STE 210
EUGENE OR
97401-8186
US

V. Phone/Fax

Practice location:
  • Phone: 541-683-3202
  • Fax: 541-868-1063
Mailing address:
  • Phone: 541-683-3202
  • Fax: 541-868-1063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA152468
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier500666195
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: