Provider Demographics
NPI:1023093986
Name:BOURLAND, WENDY (DO)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:BOURLAND
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:
Other - Last Name:HICKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:262 DANNY THOMAS PL
Mailing Address - Street 2:MAILSTOP 260
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38105-3678
Mailing Address - Country:US
Mailing Address - Phone:901-595-3300
Mailing Address - Fax:901-521-9005
Practice Address - Street 1:262 DANNY THOMAS PL
Practice Address - Street 2:MAILSTOP 260
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38105-3678
Practice Address - Country:US
Practice Address - Phone:901-595-3300
Practice Address - Fax:901-521-9005
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK43462080P0207X
TN25802080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK247612108Medicare PIN
OKH46866Medicare UPIN