Basic Information
| Provider Information | |||||||||
| NPI: | 1750341053 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOURQUE | ||||||||
| FirstName: | GLORIA | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | ANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 73410 | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997073410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004784091 | ||||||||
| FaxNumber: | 9077702390 | ||||||||
| Practice Location | |||||||||
| Address1: | 1919 LATHROP ST | ||||||||
| Address2: | STE 220 | ||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074521739 | ||||||||
| FaxNumber: | 9074522384 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 545 | AK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | NP0545 | 05 | AK | MEDICAID | GR0221 | 05 | AK | MEDICAID |