Provider Demographics
NPI:1497788632
Name:BORDUIN, LISA (PA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BORDUIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:158 N MAIN ST
Mailing Address - Street 2:PO BOX 299
Mailing Address - City:FLORIDA
Mailing Address - State:NY
Mailing Address - Zip Code:10921-1133
Mailing Address - Country:US
Mailing Address - Phone:845-651-1412
Mailing Address - Fax:845-651-1510
Practice Address - Street 1:2904 ROUTE 6
Practice Address - Street 2:
Practice Address - City:SLATE HILL
Practice Address - State:NY
Practice Address - Zip Code:10973-3810
Practice Address - Country:US
Practice Address - Phone:845-355-4611
Practice Address - Fax:845-355-2776
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009221363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1056042OtherNCCPA
NJ25MP00104200OtherPA MEDICAL LICENSE