Provider Demographics
NPI:1750341053
Name:BOURQUE, GLORIA G (ANP)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:G
Last Name:BOURQUE
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 73410
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99707-3410
Mailing Address - Country:US
Mailing Address - Phone:800-478-4091
Mailing Address - Fax:907-770-2390
Practice Address - Street 1:1919 LATHROP ST
Practice Address - Street 2:STE 220
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701
Practice Address - Country:US
Practice Address - Phone:907-452-1739
Practice Address - Fax:907-452-2384
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK545363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKNP0545Medicaid
AKGR0221Medicaid
P23354Medicare UPIN
AKNP0545Medicaid