Provider Demographics
NPI:1336164789
Name:BOURQUE, PEGGY (MSN, RN, CS, ENP)
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:
Last Name:BOURQUE
Suffix:
Gender:F
Credentials:MSN, RN, CS, ENP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6431 FANNIN ST # JJL270
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-1501
Mailing Address - Country:US
Mailing Address - Phone:713-500-3500
Mailing Address - Fax:
Practice Address - Street 1:6411 FANNIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-1501
Practice Address - Country:US
Practice Address - Phone:713-704-4060
Practice Address - Fax:713-704-6851
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX521576363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX117954105Medicaid
TX8Y1601OtherBCBS
TX117954106Medicaid
TX117954107OtherCSHCN
TX117954106Medicaid
TX8J2050Medicare PIN
TX117954107OtherCSHCN
TXP00690732Medicare PIN
TX8J1904Medicare PIN