Provider Demographics
NPI:1407031289
Name:BOURDEAU, VIRGINIA L (RPH)
Entity Type:Individual
Prefix:MS
First Name:VIRGINIA
Middle Name:L
Last Name:BOURDEAU
Suffix:
Gender:F
Credentials:RPH
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 14890
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212-4890
Mailing Address - Country:US
Mailing Address - Phone:518-525-5634
Mailing Address - Fax:518-649-4094
Practice Address - Street 1:2 EMPIRE DR STE 100
Practice Address - Street 2:
Practice Address - City:RENSSELAER
Practice Address - State:NY
Practice Address - Zip Code:12144-5730
Practice Address - Country:US
Practice Address - Phone:518-286-4899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-30
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040042183500000X
NY349073363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No183500000XPharmacy Service ProvidersPharmacist