Provider Demographics
NPI:1578984613
Name:BOURQUE, BROOKE DELHOMME (PA-C)
Entity Type:Individual
Prefix:MS
First Name:BROOKE
Middle Name:DELHOMME
Last Name:BOURQUE
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:PO BOX 98509
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70884-9509
Mailing Address - Country:US
Mailing Address - Phone:225-769-2200
Mailing Address - Fax:225-768-2185
Practice Address - Street 1:10101 PARK ROWE AVE
Practice Address - Street 2:STE. 200
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-1686
Practice Address - Country:US
Practice Address - Phone:225-769-2200
Practice Address - Fax:225-768-2185
Is Sole Proprietor?:No
Enumeration Date:2013-12-16
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200676363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2355261Medicaid
LA2355261Medicaid