Provider Demographics
NPI:1790737591
Name:BOURQUARD, RENEE A (MD)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:A
Last Name:BOURQUARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:
Practice Address - Street 1:100 WARM SPRINGS AVE
Practice Address - Street 2:STE B
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6243
Practice Address - Country:US
Practice Address - Phone:208-381-6930
Practice Address - Fax:208-381-6931
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5303208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20000048Medicare PIN