Provider Demographics
NPI:1710510565
Name:BOURLAND, PETER (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:BOURLAND
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 M ST NE APT 1113
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-7925
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:130 M ST NE APT 1113
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-7925
Practice Address - Country:US
Practice Address - Phone:336-413-9578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-20
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant