Carly Bourgeois
Individual provider Active NPI Physician Assistant · Zachary, LA
NPI 1154095479 · NPPES record last updated Aug 2, 2021
Key facts
- NPI
- 1154095479
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Physician Assistant 363A00000X
- License
- 328269 (LA)
- Practice address
- 6300 Main St
Zachary, LA 70791-4037 - Phone
- (225) 765-7163
- NPI assigned
- Aug 2, 2021
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 3
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in LA
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20210819000570 | LA | Practitioner - Physician Assistant | 4385049048 | Reassigns benefits to 2 organizations |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 328269 | LA | MD | Physician Assistant |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Acs Primary Care Physicians Louisiana PC | Physician Assistant | Current |
Accepting new patients |
| R.T. Royal Group LLC | Past |
Accepting new patients |
Locations
211 4th St
Alexandria, LA 71301
Phone (318) 473-3000
1001 Gause Blvd
Slidell, LA 70458
Phone (985) 280-2200
6300 Main St
Zachary, LA 70791
Phone (225) 570-2618
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physician Assistant | 363A00000X | 328269 | LA | Yes |
Addresses
Primary practice location
6300 Main St
Zachary, LA 70791-4037
Mailing address
6300 Main St
Zachary, LA 70791-4037
Phone (225) 765-7163
Other providers in Zachary, LA
- Otto Joseph Bonin Jr.
- Emily Calhoun Bonvillain
- Hayley T Bordes
- Fredrick J Boudreaux
- Kaitlyn Winnie Carroll Bouquet
- Danny P Bourgeois Jr.
- Ian Bourgeois
- Claire Boutte
- Jessica Bowman
- Porche' Bowman
All providers in Zachary, LA · Physician Assistant in Louisiana
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 2, 2021. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.