Provider Demographics
NPI:1356951024
Name:BOURSIQUOT, MURIELLE M (MA)
Entity type:Individual
Prefix:
First Name:MURIELLE
Middle Name:M
Last Name:BOURSIQUOT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7901 HENRY AVE APT G302
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-3072
Mailing Address - Country:US
Mailing Address - Phone:267-694-6588
Mailing Address - Fax:
Practice Address - Street 1:7901 HENRY AVE APT G302
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-3072
Practice Address - Country:US
Practice Address - Phone:267-694-6588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA29785595363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA203711803OtherSANFORD BROWN