Provider Demographics
NPI:1902911639
Name:GOURNEAU, LINDA FAYE (MD)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:FAYE
Last Name:GOURNEAU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W CENTURY AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-1401
Mailing Address - Country:US
Mailing Address - Phone:701-323-9900
Mailing Address - Fax:701-323-9911
Practice Address - Street 1:300 W CENTURY AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-1401
Practice Address - Country:US
Practice Address - Phone:701-323-9900
Practice Address - Fax:701-323-9911
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND6022207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND27069OtherBLUE CROSS/BLUE SHIELD
ND27069OtherBLUE CROSS/BLUE SHIELD
NDN712613Medicare PIN