Basic Information
| Provider Information | |||||||||
| NPI: | 1427428937 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BORDONARO | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | THOMAS | ||||||||
| OtherFirstName: | TINA | ||||||||
| OtherMiddleName: | NICOLE | ||||||||
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| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11350 MCCORMICK RD | ||||||||
| Address2: | EXECUTIVE PLAZA 1, SUITE 501 | ||||||||
| City: | HUNT VALLEY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103291071 | ||||||||
| FaxNumber: | 4103291054 | ||||||||
| Practice Location | |||||||||
| Address1: | 920 N SHENANDOAH AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | FRONT ROYAL | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5405515564 | ||||||||
| FaxNumber: | 7036421876 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2015 | ||||||||
| LastUpdateDate: | 05/31/2018 | ||||||||
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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 | 363AS0400X | C0005787 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.