Basic Information
| Provider Information | |||||||||
| NPI: | 1508482902 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOURQUE | ||||||||
| FirstName: | CASEY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7233 E BASELINE RD STE 126 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852095007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806992222 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7233 E BASELINE RD STE 126 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852095007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806992222 | ||||||||
| FaxNumber: | 4806993033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2020 | ||||||||
| LastUpdateDate: | 09/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 242372 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.