Provider Demographics
NPI:1184667297
Name:BORMAN, JACQUELINE M (PT)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:M
Last Name:BORMAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:MURGAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:370 E MAPLE AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LANGHORNE
Mailing Address - State:PA
Mailing Address - Zip Code:19047-2859
Mailing Address - Country:US
Mailing Address - Phone:215-752-4553
Mailing Address - Fax:215-752-0703
Practice Address - Street 1:370 E MAPLE AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:LANGHORNE
Practice Address - State:PA
Practice Address - Zip Code:19047-2859
Practice Address - Country:US
Practice Address - Phone:215-752-4553
Practice Address - Fax:215-752-0703
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT016952174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2292512000OtherINDEPENDENCE BLUE CROSS
PA0053616OtherAETNA
PA001614655OtherPA BLUE SHIELD
PA080081JUWMedicare ID - Type Unspecified