Provider Demographics
NPI:1952302218
Name:BORDICK, KATHLEEN CARPEN (CRNA)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:CARPEN
Last Name:BORDICK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:763 JOHNSONBURG RD
Mailing Address - Street 2:ERPG ANESTHESIA SERVICES
Mailing Address - City:SAINT MARYS
Mailing Address - State:PA
Mailing Address - Zip Code:15857-3417
Mailing Address - Country:US
Mailing Address - Phone:814-788-8562
Mailing Address - Fax:814-788-8387
Practice Address - Street 1:763 JOHNSONBURG RD
Practice Address - Street 2:ERPG ANESTHESIA SERVICES
Practice Address - City:SAINT MARYS
Practice Address - State:PA
Practice Address - Zip Code:15857-3417
Practice Address - Country:US
Practice Address - Phone:814-788-8562
Practice Address - Fax:814-788-8387
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN244084L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARN244084LOtherRN LICENSE
PAP16075Medicare UPIN
PARN244084LOtherRN LICENSE