Provider Demographics
NPI:1003678533
Name:BORNEKE, KAITLYN (PA)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:BORNEKE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 8674
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56002-8674
Mailing Address - Country:US
Mailing Address - Phone:507-625-1811
Mailing Address - Fax:507-625-4643
Practice Address - Street 1:1400 MADISON AVE STE 400A
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6805
Practice Address - Country:US
Practice Address - Phone:507-389-8538
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-29
Last Update Date:2025-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN14784363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant