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General NPI Number Information
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NPI Number | 1619475530
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Entity Type | Individual
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Provider Name | KRISTIN BOURG PA
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Gender | Female
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Dates
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Enumeration Date | 01/25/2018
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Last Update Date | 11/13/2018
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Provider Practice Location Address
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Address Line | 1968 PEACHTREE RD NW
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City | ATLANTA
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State | GA
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Zip | 30309
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Country | US
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Telephone | 404-605-2800
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Fax |
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Provider Business Mailing Address
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Address Line | 2001 BUTTERFIELD RD STE 300
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City | DOWNERS GROVE
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State | IL
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Zip | 60515-1069
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Country | US
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Telephone | 630-725-2730
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Fax | 844-205-5691
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | RN008722
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License Number State | GA
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