Provider Demographics
NPI:1720688914
Name:DEBOURGE, DUSTIN (MSN, AGNP-BC)
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:DEBOURGE
Suffix:
Gender:M
Credentials:MSN, AGNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:785 ELKRIDGE LANDING RD STE 300
Mailing Address - Street 2:
Mailing Address - City:LINTHICUM HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:21090-2958
Mailing Address - Country:US
Mailing Address - Phone:443-275-9800
Mailing Address - Fax:844-469-0955
Practice Address - Street 1:6 LUCERNE CT
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-2931
Practice Address - Country:US
Practice Address - Phone:537-303-8025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020038126363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology