Provider Demographics
NPI:1790019271
Name:BORGER, BONITA THIBAULT (APRN)
Entity Type:Individual
Prefix:MS
First Name:BONITA
Middle Name:THIBAULT
Last Name:BORGER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MISS
Other - First Name:BONITA
Other - Middle Name:SUZANNE
Other - Last Name:THIBAULT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:205 E UNIVERSITY AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-6821
Mailing Address - Country:US
Mailing Address - Phone:877-800-5722
Mailing Address - Fax:512-869-2940
Practice Address - Street 1:1221 W BEN WHITE BLVD STE 200B
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-7002
Practice Address - Country:US
Practice Address - Phone:877-800-5722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-30
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT89081163W00000X
TX855718163W00000X
IL041-354024163W00000X
CT004225363LF0000X
IL209008456363LF0000X
TXAP126248363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004236346Medicaid