Basic Information
| Provider Information | |||||||||
| NPI: | 1275608226 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BORRA | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 134 HOMER AVE | ||||||||
| Address2: | |||||||||
| City: | CORTLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130451206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077588019 | ||||||||
| FaxNumber: | 6077588210 | ||||||||
| Practice Location | |||||||||
| Address1: | 135 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CORTLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130451226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077588019 | ||||||||
| FaxNumber: | 6077588210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2006 | ||||||||
| LastUpdateDate: | 02/26/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | F000921 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 02163808 | 05 | NY | MEDICAID | F000921 | 01 | NY | NYS LIC # | OTHER |