Provider Demographics
NPI:1003973231
Name:BOURBON, REBECCA LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LYNN
Last Name:BOURBON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PRESBYTERIAN HEALTHCARE SERVICES
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-6770
Mailing Address - Fax:
Practice Address - Street 1:4005 HIGH RESORT BLVD SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-5906
Practice Address - Country:US
Practice Address - Phone:505-462-6000
Practice Address - Fax:505-462-8472
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM92-PA09363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMPA920091Medicaid
NMPA920091Medicare ID - Type UnspecifiedAETNA MEDICARE