Provider Demographics
NPI:1982066783
Name:BOURGEOIS, BRAD
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:
Last Name:BOURGEOIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5842 SUNDOWN CIR APT 621
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822-9452
Mailing Address - Country:US
Mailing Address - Phone:985-209-7381
Mailing Address - Fax:
Practice Address - Street 1:201 N LAKEMONT AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-3228
Practice Address - Country:US
Practice Address - Phone:407-790-4205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-22
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP08638363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2416243Medicaid
LA2416243Medicaid