Basic Information
| Provider Information | |||||||||
| NPI: | 1275600033 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOURGON | ||||||||
| FirstName: | SHAWN | ||||||||
| MiddleName: | BRIDGET | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | BOURGON | ||||||||
| OtherFirstName: | BRIDGET | ||||||||
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| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3440 E LA PALMA AVE | ||||||||
| Address2: | |||||||||
| City: | ANAHEIM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928062020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889882800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3440 E LA PALMA AVE | ||||||||
| Address2: | |||||||||
| City: | ANAHEIM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928062020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889882800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2006 | ||||||||
| LastUpdateDate: | 12/19/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA14984 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.