Provider Demographics
NPI:1134184179
Name:BOURGEAULT, KAREN J (PAC)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:J
Last Name:BOURGEAULT
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 BICENTENNIAL HWY
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01118-1962
Mailing Address - Country:US
Mailing Address - Phone:413-733-4101
Mailing Address - Fax:413-796-6821
Practice Address - Street 1:305 BICENTENNIAL HWY
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01118-1962
Practice Address - Country:US
Practice Address - Phone:413-733-4101
Practice Address - Fax:413-796-6821
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA922363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAP0835Medicare PIN
MAS55882Medicare UPIN