Provider Demographics
NPI:1063690931
Name:BOURNE, KENRICK CARLYLE (PA-C)
Entity type:Individual
Prefix:MR
First Name:KENRICK
Middle Name:CARLYLE
Last Name:BOURNE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1695 S SAN JACINTO AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92583-5103
Mailing Address - Country:US
Mailing Address - Phone:951-330-3100
Mailing Address - Fax:
Practice Address - Street 1:1695 S SAN JACINTO AVE STE C
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583-5103
Practice Address - Country:US
Practice Address - Phone:951-330-3100
Practice Address - Fax:951-380-8596
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-04
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA12018363A00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily