Provider Demographics
NPI:1902808843
Name:BOURQUE-MORENO, MARCIA (CRNA)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:
Last Name:BOURQUE-MORENO
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 CLEVELAND ST
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:MA
Mailing Address - Zip Code:02056-1048
Mailing Address - Country:US
Mailing Address - Phone:508-520-2302
Mailing Address - Fax:
Practice Address - Street 1:25 WELLS ST
Practice Address - Street 2:
Practice Address - City:WESTERLY
Practice Address - State:RI
Practice Address - Zip Code:02891-2922
Practice Address - Country:US
Practice Address - Phone:401-596-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA193379367500000X
RIAPRN01004367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered