Provider Demographics
NPI:1841787785
Name:BOURGUIGNON, EMILY R (PA-C)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:R
Last Name:BOURGUIGNON
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 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:3263 EATON RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6830
Practice Address - Country:US
Practice Address - Phone:920-433-6000
Practice Address - Fax:920-433-6009
Is Sole Proprietor?:No
Enumeration Date:2018-04-17
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI4440363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1151531OtherNATIONAL COMMISSION ON CERTIFIED PHYSICIANS ASSISTANTS