Provider Demographics
NPI:1265862890
Name:BORNTRAGER, KERWIN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KERWIN
Middle Name:
Last Name:BORNTRAGER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 FOREST HILL AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230-1121
Mailing Address - Country:US
Mailing Address - Phone:443-717-4334
Mailing Address - Fax:
Practice Address - Street 1:1313 FOREST HILL AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21230-1121
Practice Address - Country:US
Practice Address - Phone:443-717-4334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-18
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0004929363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant