Provider Demographics
NPI:1851105746
Name:BOURET, ELISHA
Entity type:Individual
Prefix:
First Name:ELISHA
Middle Name:
Last Name:BOURET
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135B W 168TH ST APT 5B
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10452-3472
Mailing Address - Country:US
Mailing Address - Phone:347-500-9976
Mailing Address - Fax:
Practice Address - Street 1:579 COURTLANDT AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-5013
Practice Address - Country:US
Practice Address - Phone:718-485-2100
Practice Address - Fax:718-485-2101
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-03
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program