Basic Information
| Provider Information | |||||||||
| NPI: | 1871544981 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOURQUE | ||||||||
| FirstName: | ANNE MARIE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 950 WINTER ST | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | WALTHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024511424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7814198354 | ||||||||
| FaxNumber: | 7814198479 | ||||||||
| Practice Location | |||||||||
| Address1: | 950 WINTER ST | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | WALTHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024511424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7814198354 | ||||||||
| FaxNumber: | 7814198479 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2006 | ||||||||
| LastUpdateDate: | 07/30/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 132090 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 0706779 | 05 | MA | MEDICAID |