Provider Demographics
NPI:1871195966
Name:BORUTA, KYLIE MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:MARIE
Last Name:BORUTA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 158
Mailing Address - Street 2:
Mailing Address - City:GOULDSBORO
Mailing Address - State:PA
Mailing Address - Zip Code:18424-0158
Mailing Address - Country:US
Mailing Address - Phone:570-851-7863
Mailing Address - Fax:
Practice Address - Street 1:34 NORTHEAST DR
Practice Address - Street 2:
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-2732
Practice Address - Country:US
Practice Address - Phone:717-920-9312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA005334363A00000X
PAMA051545363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant