Provider Demographics
NPI:1851042337
Name:BOURKE, BRIAN
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:BOURKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 SKYWAY DR
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94591-4026
Mailing Address - Country:US
Mailing Address - Phone:510-703-0402
Mailing Address - Fax:
Practice Address - Street 1:70 DORAY DR
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523-2981
Practice Address - Country:US
Practice Address - Phone:510-703-0402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-15
Last Update Date:2022-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date: