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1053659649 NPI number — MAMAWAH ISATA BOURQUE P.T.

NPI Number: 1053659649
Health Care Provider/Practitioner: MAMAWAH ISATA BOURQUE P.T.

Information about “1053659649” NPI (MAMAWAH ISATA BOURQUE P.T.) exists in 1053659649 in HTML format HTML  |  1053659649 in plain Text format TXT  |  1053659649 in PDF (Portable Document Format) PDF  |  1053659649 in an XML format XML  formats.

NPI Number : 1053659649 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1053659649",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "Y",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "BOURQUE",
    "FirstName": "MAMAWAH",
    "MiddleName": "ISATA",
    "NamePrefix": "DR.",
    "NameSuffix": null,
    "Credential": "P.T.",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "14332 MONTFORT DR",
    "SecondLineMailingAddress": "#4101",
    "MailingAddressCityName": "DALLAS",
    "MailingAddressStateName": "TX",
    "MailingAddressPostalCode": "75254-8486",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "713-256-4708",
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "14332 MONTFORT DR",
    "SecondLinePracticeLocationAddress": "#4101",
    "PracticeLocationAddressCityName": "DALLAS",
    "PracticeLocationAddressStateName": "TX",
    "PracticeLocationAddressPostalCode": "75254-8486",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "713-256-4708",
    "PracticeLocationAddressFaxNumber": null,
    "EnumerationDate": "01/16/2013",
    "LastUpdateDate": "01/16/2013",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "F",
    "Gender": "Female",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "225100000X",
        "TaxonomyName": "Physical Therapist",
        "LicenseNumber": "1210663",
        "LicenseNumberStateCode": "TX",
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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