Provider Demographics
NPI:1346674264
Name:BORUKHOV, FREDA (PA-C)
Entity Type:Individual
Prefix:
First Name:FREDA
Middle Name:
Last Name:BORUKHOV
Suffix:
Gender:F
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 1:14905 79TH AVE APT 623
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-3832
Mailing Address - Country:US
Mailing Address - Phone:347-893-6487
Mailing Address - Fax:
Practice Address - Street 1:14905 79TH AVE APT 623
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11367-3832
Practice Address - Country:US
Practice Address - Phone:347-893-6487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-27
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0166541363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant