Provider Demographics
NPI:1679125934
Name:BORJA, GIBRAN
Entity Type:Individual
Prefix:
First Name:GIBRAN
Middle Name:
Last Name:BORJA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6921 S JORDAN VILLAGE RD
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84084-1789
Mailing Address - Country:US
Mailing Address - Phone:801-448-2218
Mailing Address - Fax:
Practice Address - Street 1:6921 S JORDAN VILLAGE RD
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84084-1789
Practice Address - Country:US
Practice Address - Phone:801-448-2218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-16
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT13252997-8002363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program