Basic Information
Provider Information | |||||||||
NPI: | 1295281897 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BORGELLA | ||||||||
FirstName: | MARIE | ||||||||
MiddleName: | R. | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GOIN | ||||||||
OtherFirstName: | MARIE | ||||||||
OtherMiddleName: | R. | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RN | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 6550 FANNIN ST | ||||||||
Address2: | SUITE 1101 | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770302717 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7134410006 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 6550 FANNIN ST | ||||||||
Address2: | SUITE 1101 | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770302717 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7134410006 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/01/2016 | ||||||||
LastUpdateDate: | 12/08/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | AP131724 | TX | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
ID | Type | State | Issuer | Description | 8191NZ | 01 | TX | BCBS | OTHER | 366121701 | 05 | TX |   | MEDICAID |