Basic Information
| Provider Information | |||||||||
| NPI: | 1922502772 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOURGEOIS | ||||||||
| FirstName: | TRACI | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 324 DULLES DRIVE | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3377061571 | ||||||||
| FaxNumber: | 3372612697 | ||||||||
| Practice Location | |||||||||
| Address1: | 2390 WEST CONGRESS STREET | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372616000 | ||||||||
| FaxNumber: | 3372616003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2018 | ||||||||
| LastUpdateDate: | 10/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 326107 | LA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2465104 | 05 | LA | MEDICAID |