Provider Demographics
NPI:1588603443
Name:BOURDAGE, KERI L (PAC)
Entity Type:Individual
Prefix:MS
First Name:KERI
Middle Name:L
Last Name:BOURDAGE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:KERL
Other - Middle Name:LYNN
Other - Last Name:BOURDAGE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 918025
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-8025
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-392-3000
Practice Address - Fax:352-392-8530
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103318363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292626100Medicaid
FLU5822YMedicare PIN
FL292626100Medicaid
U5822ZMedicare PIN