Provider Demographics
NPI:1104890631
Name:BOURESSA, ELIZABETH ANNE HESKETT (MD)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:ANNE HESKETT
Last Name:BOURESSA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:HESKETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1189
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:734 ELM ST SW
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-1934
Practice Address - Country:US
Practice Address - Phone:541-812-5111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD203466208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR082623Medicaid
OR082623Medicaid