Basic Information
| Provider Information | |||||||||
| NPI: | 1619432192 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BORJA | ||||||||
| FirstName: | JANINE BEATRICE | ||||||||
| MiddleName: | GOZA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GOZA | ||||||||
| OtherFirstName: | JANINE BEATRICE | ||||||||
| OtherMiddleName: | JOSE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8080 EDEN RD APT 158 | ||||||||
| Address2: | |||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553447675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6124131512 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8201 E RIVERSIDE BLVD | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611142300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159717000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2019 | ||||||||
| LastUpdateDate: | 05/26/2019 | ||||||||
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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 | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.