Provider Demographics
NPI:1134163207
Name:BOURGEOIS, BECKY ANN (CRNA)
Entity type:Individual
Prefix:
First Name:BECKY
Middle Name:ANN
Last Name:BOURGEOIS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2429
Mailing Address - Country:US
Mailing Address - Phone:504-842-9119
Mailing Address - Fax:504-842-6997
Practice Address - Street 1:2500 BELLE CHASSE HWY
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70056
Practice Address - Country:US
Practice Address - Phone:504-391-5157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN028526367500000X
LAAP01320367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSD5173589Medicaid
LA1396401Medicaid
LA595447061Medicare PIN