Provider Demographics
NPI:1871736959
Name:BOURASSA, AMY L (MD)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:L
Last Name:BOURASSA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:556 WESTON DR
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-3730
Mailing Address - Country:US
Mailing Address - Phone:408-420-3209
Mailing Address - Fax:
Practice Address - Street 1:556 WESTON DR
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-3730
Practice Address - Country:US
Practice Address - Phone:408-420-3209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-20
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG86603207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine