Provider Demographics
NPI:1578612867
Name:BOURCIER, LISA (NP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BOURCIER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1447 N HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-4727
Mailing Address - Country:US
Mailing Address - Phone:989-583-6000
Mailing Address - Fax:
Practice Address - Street 1:16440 GRATIOT RD
Practice Address - Street 2:
Practice Address - City:HEMLOCK
Practice Address - State:MI
Practice Address - Zip Code:48626-8655
Practice Address - Country:US
Practice Address - Phone:989-583-0660
Practice Address - Fax:989-583-0669
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704147440363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN44340003Medicare ID - Type Unspecified