Provider Demographics
NPI:1164816831
Name:BOURG, MALLORY
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:BOURG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-526-0006
Mailing Address - Fax:225-765-9291
Practice Address - Street 1:7777 HENNESSY BLVD
Practice Address - Street 2:SUITE 701
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4300
Practice Address - Country:US
Practice Address - Phone:225-765-5864
Practice Address - Fax:225-765-2013
Is Sole Proprietor?:No
Enumeration Date:2015-03-20
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200789363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant