Provider Demographics
NPI:1053468199
Name:BOREN, JUSTIN LUKE (PA)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:LUKE
Last Name:BOREN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:410 42ND AVE N STE 400
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37209-3658
Mailing Address - Country:US
Mailing Address - Phone:615-329-7887
Mailing Address - Fax:
Practice Address - Street 1:832 WESTOVER DR STE 200
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-4843
Practice Address - Country:US
Practice Address - Phone:931-830-3033
Practice Address - Fax:931-388-3401
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA1296363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA874485289BMedicaid
TNP00382564OtherRAILROAD MEDICARE
AL009941922Medicaid
GA874485289AMedicaid
TN4142242OtherBLUE CROSS