Provider Demographics
NPI:1306590633
Name:BOURASS, SOUFYANE
Entity type:Individual
Prefix:
First Name:SOUFYANE
Middle Name:
Last Name:BOURASS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 LOCHNAGAR MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-6672
Mailing Address - Country:US
Mailing Address - Phone:812-870-8683
Mailing Address - Fax:
Practice Address - Street 1:1400 OLD DIXIE HWY
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-4190
Practice Address - Country:US
Practice Address - Phone:904-824-0724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-06
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11017959363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health