Provider Demographics
NPI:1720502628
Name:BOURGEOIS, KEITH JAMES (FNP-C)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:JAMES
Last Name:BOURGEOIS
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3073 WHITE MOUNTAIN HWY
Mailing Address - Street 2:
Mailing Address - City:NORTH CONWAY
Mailing Address - State:NH
Mailing Address - Zip Code:03860-7101
Mailing Address - Country:US
Mailing Address - Phone:603-356-5472
Mailing Address - Fax:603-356-9647
Practice Address - Street 1:3073 WHITE MOUNTAIN HWY
Practice Address - Street 2:
Practice Address - City:NORTH CONWAY
Practice Address - State:NH
Practice Address - Zip Code:03860-7101
Practice Address - Country:US
Practice Address - Phone:603-356-5472
Practice Address - Fax:603-356-9647
Is Sole Proprietor?:No
Enumeration Date:2017-08-01
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP171069363LF0000X
NH111595-23363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily