Provider Demographics
NPI:1962818013
Name:BOURDEAU, MEREDITH (PA-C, ATC)
Entity Type:Individual
Prefix:
First Name:MEREDITH
Middle Name:
Last Name:BOURDEAU
Suffix:
Gender:F
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HARRISON
Mailing Address - State:NY
Mailing Address - Zip Code:10604-2100
Mailing Address - Country:US
Mailing Address - Phone:802-272-6078
Mailing Address - Fax:
Practice Address - Street 1:55 PALMER AVE
Practice Address - Street 2:
Practice Address - City:BRONXVILLE
Practice Address - State:NY
Practice Address - Zip Code:10708-3403
Practice Address - Country:US
Practice Address - Phone:802-272-6078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002025-12255A2300X
CT4118363A00000X
NY363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer