Provider Demographics
NPI:1124027263
Name:BOURNE, MICHELLE L (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:BOURNE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:L
Other - Last Name:TRUMBLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:4008 WOOD CASTLE ST
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-1795
Mailing Address - Country:US
Mailing Address - Phone:405-919-8490
Mailing Address - Fax:
Practice Address - Street 1:2080 HWY 9 WEST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072
Practice Address - Country:US
Practice Address - Phone:405-322-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1164363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100138520AMedicaid
OKOKA105487Medicare PIN