Provider Demographics
NPI:1669564779
Name:BOURQUE, PAUL FRANCIS (CO)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:FRANCIS
Last Name:BOURQUE
Suffix:
Gender:M
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2704 STONE AVE
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-3803
Mailing Address - Country:US
Mailing Address - Phone:386-738-2833
Mailing Address - Fax:
Practice Address - Street 1:1222 ORANGE AVE
Practice Address - Street 2:STE B
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-4918
Practice Address - Country:US
Practice Address - Phone:407-740-7772
Practice Address - Fax:407-539-1791
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLORT6174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist