Provider Demographics
NPI:1780641530
Name:BORST, ALICIA R (PAC)
Entity Type:Individual
Prefix:MRS
First Name:ALICIA
Middle Name:R
Last Name:BORST
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MS
Other - First Name:ALICIA
Other - Middle Name:R
Other - Last Name:GREGG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:3960 W. WAINWRIGHT
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713
Mailing Address - Country:US
Mailing Address - Phone:208-384-9023
Mailing Address - Fax:208-388-1683
Practice Address - Street 1:3960 W. WAINWRIGHT
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713
Practice Address - Country:US
Practice Address - Phone:208-384-9023
Practice Address - Fax:208-388-1683
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC787363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0078PAMedicaid
P712911955Medicare ID - Type Unspecified
P71291Medicare UPIN
SC0078PAMedicaid