Provider Demographics
NPI:1033424429
Name:BORRON FAMILY MEDICINE PLLC
Entity Type:Organization
Organization Name:BORRON FAMILY MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BROOKNEY
Authorized Official - Middle Name:RAEANNE
Authorized Official - Last Name:BORRON
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, FNP-C
Authorized Official - Phone:208-866-1428
Mailing Address - Street 1:790 W USTICK RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-5558
Mailing Address - Country:US
Mailing Address - Phone:208-639-3990
Mailing Address - Fax:208-639-3992
Practice Address - Street 1:790 W USTICK RD
Practice Address - Street 2:STE 110
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-5558
Practice Address - Country:US
Practice Address - Phone:208-639-3990
Practice Address - Fax:208-639-3992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-10
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP2300X
IDNP-923A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1033424429Medicaid