Provider Demographics
NPI:1780236489
Name:BOURDEAU, KAITLIN M (PA)
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:M
Last Name:BOURDEAU
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 1:135 BRAKESHOE PL
Mailing Address - Street 2:
Mailing Address - City:MAHWAH
Mailing Address - State:NJ
Mailing Address - Zip Code:07430-1102
Mailing Address - Country:US
Mailing Address - Phone:551-804-7432
Mailing Address - Fax:
Practice Address - Street 1:1255 BROAD ST STE 201A
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-3061
Practice Address - Country:US
Practice Address - Phone:973-842-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-12
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
25MP00528000363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant