Provider Demographics
NPI:1407828569
Name:BORGSTADT, MARY L (ARNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:BORGSTADT
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 12TH ST SE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98002-6709
Mailing Address - Country:US
Mailing Address - Phone:253-876-7990
Mailing Address - Fax:
Practice Address - Street 1:735 12TH ST SE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-6709
Practice Address - Country:US
Practice Address - Phone:253-876-7990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00157592207RC0000X
WAAP30006913363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9645029Medicaid
WAP0026399OtherRAIL ROAD MEDICARE
WA7235BOOtherINDIVIDUAL BLUE SHIED
WA9645029Medicaid
WAP0026399OtherRAIL ROAD MEDICARE