Basic Information
| Provider Information | |||||||||
| NPI: | 1619985231 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BORMAN | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 31798 RIO VISTA RD | ||||||||
| Address2: | |||||||||
| City: | PARKER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853448509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9288908202 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1200 W MOHAVE RD | ||||||||
| Address2: | |||||||||
| City: | PARKER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853446349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286699201 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 04/03/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN114864 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 618564 | 05 | AZ | MEDICAID |