Provider Demographics
NPI:1669085437
Name:BOURGEOIS, RYAN (FNP)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:BOURGEOIS
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15304 SEVENTEEN LAKES BLVD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:TX
Mailing Address - Zip Code:76262-3739
Mailing Address - Country:US
Mailing Address - Phone:818-209-2501
Mailing Address - Fax:
Practice Address - Street 1:2917 CROCKET STREET
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107
Practice Address - Country:US
Practice Address - Phone:817-385-4814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-31
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1010773363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily