Provider Demographics
NPI:1992307078
Name:VAN BOURG, ANN (PA)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:
Last Name:VAN BOURG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13727 CONDESA DR
Mailing Address - Street 2:
Mailing Address - City:DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92014-3301
Mailing Address - Country:US
Mailing Address - Phone:760-331-7425
Mailing Address - Fax:
Practice Address - Street 1:6655 ALVARADO RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5208
Practice Address - Country:US
Practice Address - Phone:619-287-3270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-12
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1992307078Medicaid