Provider Demographics
NPI:1669623971
Name:BURGOYNE, MICHELLE ANNE (PA)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:ANNE
Last Name:BURGOYNE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7045 YOUREE DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5108
Mailing Address - Country:US
Mailing Address - Phone:318-798-3763
Mailing Address - Fax:318-798-2267
Practice Address - Street 1:7045 YOUREE DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5108
Practice Address - Country:US
Practice Address - Phone:318-798-3763
Practice Address - Fax:318-798-2267
Is Sole Proprietor?:No
Enumeration Date:2008-10-06
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA200211363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1325619Medicaid
LA57561PG14Medicare PIN