Basic Information
Provider Information | |||||||||
NPI: | 1083774541 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MITCHELL BORISKIN, F.N.P., P.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1460 G ST | ||||||||
Address2: |   | ||||||||
City: | SPRINGFIELD | ||||||||
State: | OR | ||||||||
PostalCode: | 974774112 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5417264400 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1460 G ST | ||||||||
Address2: |   | ||||||||
City: | SPRINGFIELD | ||||||||
State: | OR | ||||||||
PostalCode: | 974774112 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5417264400 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/12/2006 | ||||||||
LastUpdateDate: | 08/27/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BORISKIN | ||||||||
AuthorizedOfficialFirstName: | MITCHELL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 5417264400 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | FNP | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 085073033N | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 175281 | 05 | OR |   | MEDICAID |