Provider Demographics
NPI:1710070131
Name:BORST, JACQUELYN R (PA-C)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:R
Last Name:BORST
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:R
Other - Last Name:LAGEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:174 BUCKAROO LANE
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTE
Mailing Address - State:PA
Mailing Address - Zip Code:16823
Mailing Address - Country:US
Mailing Address - Phone:814-353-1030
Mailing Address - Fax:814-353-1053
Practice Address - Street 1:100 N ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17822-9800
Practice Address - Country:US
Practice Address - Phone:814-353-1030
Practice Address - Fax:814-353-1053
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052690363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical