Provider Demographics
NPI:1982066783
Name:BOURGEOIS, BRAD
Entity type:Individual
Prefix:
First Name:BRAD
Middle Name:
Last Name:BOURGEOIS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 WESTBANK EXPY
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:LA
Mailing Address - Zip Code:70053-5616
Mailing Address - Country:US
Mailing Address - Phone:504-364-1844
Mailing Address - Fax:
Practice Address - Street 1:315 WESTBANK EXPY
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70053-5616
Practice Address - Country:US
Practice Address - Phone:504-364-1844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-22
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP08638363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2416243Medicaid
LA2416243Medicaid