Provider Demographics
NPI:1205823036
Name:BOURGAULT, CHERYL R (PA C)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:R
Last Name:BOURGAULT
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 1:360 S GARDEN WAY STE 210
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-8186
Mailing Address - Country:US
Mailing Address - Phone:541-683-3202
Mailing Address - Fax:541-868-1063
Practice Address - Street 1:360 S GARDEN WAY
Practice Address - Street 2:SUITE 210
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-8173
Practice Address - Country:US
Practice Address - Phone:541-683-3202
Practice Address - Fax:541-868-1063
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA152468363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500666195Medicaid
WA8409955OtherCHPW
WA8409955Medicaid
WA0203556OtherL & I
911019392OtherCOMMERCIAL
WA8409955Medicaid
G8857456Medicare ID - Type Unspecified