Basic Information
| Provider Information | |||||||||
| NPI: | 1568900678 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BORUCKI | ||||||||
| FirstName: | HEIDI | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 N SUMMIT ST FL 7 | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436041531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196908811 | ||||||||
| FaxNumber: | 4196976750 | ||||||||
| Practice Location | |||||||||
| Address1: | 2751 BAY PARK DR STE 201 | ||||||||
| Address2: | |||||||||
| City: | OREGON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436164922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196908811 | ||||||||
| FaxNumber: | 4196976750 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2017 | ||||||||
| LastUpdateDate: | 08/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5601008128 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 50.006491RX | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.