Provider Demographics
NPI:1114222304
Name:BORUKHOW, MARINA (PA)
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:BORUKHOW
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6915 YELLOWSTONE BLVD
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-9406
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6915 YELLOWSTONE BLVD
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-9406
Practice Address - Country:US
Practice Address - Phone:718-360-9550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-19
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY013992-1OtherLICENSE