Basic Information
| Provider Information | |||||||||
| NPI: | 1497788632 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BORDUIN | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 158 N MAIN ST | ||||||||
| Address2: | PO BOX 299 | ||||||||
| City: | FLORIDA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109211133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8456511412 | ||||||||
| FaxNumber: | 8456511510 | ||||||||
| Practice Location | |||||||||
| Address1: | 2904 ROUTE 6 | ||||||||
| Address2: | |||||||||
| City: | SLATE HILL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109733810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453554611 | ||||||||
| FaxNumber: | 8453552776 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 009221 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1056042 | 01 | NCCPA | OTHER | 25MP00104200 | 01 | NJ | PA MEDICAL LICENSE | OTHER |