Provider Demographics
NPI:1275600033
Name:BOURGON, SHAWN BRIDGET (PA)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:BRIDGET
Last Name:BOURGON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:BRIDGET
Other - Middle Name:
Other - Last Name:BOURGON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:3440 E LA PALMA AVE
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92806-2020
Mailing Address - Country:US
Mailing Address - Phone:888-988-2800
Mailing Address - Fax:
Practice Address - Street 1:3440 E LA PALMA AVE
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806-2020
Practice Address - Country:US
Practice Address - Phone:888-988-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14984363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant