Provider Demographics
NPI:1629810585
Name:PETER BOURQUE NP
Entity type:Organization
Organization Name:PETER BOURQUE NP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:RALPH
Authorized Official - Last Name:BOURQUE
Authorized Official - Suffix:JR
Authorized Official - Credentials:NP
Authorized Official - Phone:860-960-6675
Mailing Address - Street 1:2813 MCDOUGALL DR
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-4153
Mailing Address - Country:US
Mailing Address - Phone:860-960-6675
Mailing Address - Fax:
Practice Address - Street 1:1650 SYCAMORE AVE
Practice Address - Street 2:
Practice Address - City:BOHEMIA
Practice Address - State:NY
Practice Address - Zip Code:11716-1738
Practice Address - Country:US
Practice Address - Phone:631-317-1024
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-11
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty