Provider Demographics
NPI:1780399485
Name:BOURQUE, SHAYNE (PA-C)
Entity type:Individual
Prefix:MR
First Name:SHAYNE
Middle Name:
Last Name:BOURQUE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 FERRY ST STE 302
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-5081
Mailing Address - Country:US
Mailing Address - Phone:603-333-1471
Mailing Address - Fax:603-255-7286
Practice Address - Street 1:300 MAIN ST
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03060-4635
Practice Address - Country:US
Practice Address - Phone:603-333-1471
Practice Address - Fax:603-255-7286
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-17
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NH2822363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant