Provider Demographics
NPI:1528473212
Name:BRUNSON, LINDSAY BOURG (PA-C)
Entity type:Individual
Prefix:MRS
First Name:LINDSAY
Middle Name:BOURG
Last Name:BRUNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:LINDSAY
Other - Middle Name:NICOLE
Other - Last Name:BOURG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16777 MEDICAL CENTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816
Mailing Address - Country:US
Mailing Address - Phone:225-761-5200
Mailing Address - Fax:
Practice Address - Street 1:16777 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-3254
Practice Address - Country:US
Practice Address - Phone:225-761-5191
Practice Address - Fax:225-761-5450
Is Sole Proprietor?:No
Enumeration Date:2014-06-22
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.200726363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2375270Medicaid
MS02632247Medicaid
LA2375270Medicaid