Basic Information
| Provider Information | |||||||||
| NPI: | 1053468199 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOREN | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | LUKE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 53 CENTURY BLVD STE 120 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372143693 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153466213 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1222 TROTWOOD AVE STE 211 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384016405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9313803033 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2007 | ||||||||
| LastUpdateDate: | 11/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA1296 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 874485289A | 05 | GA | MEDICAID | 874485289B | 05 | GA | MEDICAID | 009941922 | 05 | AL | MEDICAID | P00382564 | 01 | TN | RAILROAD MEDICARE | OTHER | 4142242 | 01 | TN | BLUE CROSS | OTHER |