Provider Demographics
NPI:1205822764
Name:BORNAK, GARY (MSPT)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:BORNAK
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4609 EASY ST
Mailing Address - Street 2:
Mailing Address - City:WEST MIFFLIN
Mailing Address - State:PA
Mailing Address - Zip Code:15122-1966
Mailing Address - Country:US
Mailing Address - Phone:412-462-1191
Mailing Address - Fax:
Practice Address - Street 1:2279B MAIN ST
Practice Address - Street 2:
Practice Address - City:MUNHALL
Practice Address - State:PA
Practice Address - Zip Code:15120-2652
Practice Address - Country:US
Practice Address - Phone:412-461-1191
Practice Address - Fax:412-462-1182
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT008598L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1011849610001Medicaid
PA1011849610001Medicaid