Provider Demographics
NPI: | 1518290337 |
---|---|
Name: | BORRELLI, ELENA (PA-C) |
Entity Type: | Individual |
Prefix: | MRS |
First Name: | ELENA |
Middle Name: | |
Last Name: | BORRELLI |
Suffix: | |
Gender: | F |
Credentials: | PA-C |
Other - Prefix: | |
Other - First Name: | ELENA |
Other - Middle Name: | |
Other - Last Name: | AMATO |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | |
Mailing Address - Street 1: | 13719 23 MILE RD |
Mailing Address - Street 2: | STE 146 |
Mailing Address - City: | SHELBY TOWNSHIP |
Mailing Address - State: | MI |
Mailing Address - Zip Code: | 48315-2907 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 586-212-6915 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 13719 23 MILE RD # 146 |
Practice Address - Street 2: | |
Practice Address - City: | SHELBY TOWNSHIP |
Practice Address - State: | MI |
Practice Address - Zip Code: | 48315-2907 |
Practice Address - Country: | US |
Practice Address - Phone: | 248-266-1355 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2009-09-11 |
Last Update Date: | 2021-12-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MI | 5601005627 | 363AS0400X, 363A00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | |
No | 363AS0400X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MI | 12024128 | Other | CAQH |