Provider Demographics
NPI:1871744854
Name:BOURG, TRACY B (NP)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:B
Last Name:BOURG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3909 LAPALCO BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HARVEY
Mailing Address - State:LA
Mailing Address - Zip Code:70058-2302
Mailing Address - Country:US
Mailing Address - Phone:504-349-6900
Mailing Address - Fax:504-340-4305
Practice Address - Street 1:3909 LAPALCO BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:HARVEY
Practice Address - State:LA
Practice Address - Zip Code:70058-2302
Practice Address - Country:US
Practice Address - Phone:504-349-6900
Practice Address - Fax:504-340-4305
Is Sole Proprietor?:No
Enumeration Date:2008-10-08
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1964363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1964OtherTEMP NP LICENSE