Provider Demographics
NPI:1134569551
Name:BOURG, DAVID (APRN, CNP)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:BOURG
Suffix:
Gender:M
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:DAVID
Other - Middle Name:
Other - Last Name:BOURG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN, CNP
Mailing Address - Street 1:3133 MATHILDE MARIE DR
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:LA
Mailing Address - Zip Code:70359-4535
Mailing Address - Country:US
Mailing Address - Phone:985-688-4598
Mailing Address - Fax:
Practice Address - Street 1:1201 KENNETH ST
Practice Address - Street 2:
Practice Address - City:MORGAN CITY
Practice Address - State:LA
Practice Address - Zip Code:70380-1353
Practice Address - Country:US
Practice Address - Phone:985-384-3355
Practice Address - Fax:985-384-2884
Is Sole Proprietor?:No
Enumeration Date:2013-06-29
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP07365363LA2100X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care