Provider Demographics
NPI:1003876483
Name:BORTHWICK, DIANN ELLEN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:DIANN
Middle Name:ELLEN
Last Name:BORTHWICK
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 1:9129 PRELOG LN
Mailing Address - Street 2:
Mailing Address - City:KIRTLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44094-5182
Mailing Address - Country:US
Mailing Address - Phone:440-256-9129
Mailing Address - Fax:
Practice Address - Street 1:9129 PRELOG LN
Practice Address - Street 2:
Practice Address - City:KIRTLAND
Practice Address - State:OH
Practice Address - Zip Code:44094-5182
Practice Address - Country:US
Practice Address - Phone:440-256-9129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50001360363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00654Medicare UPIN
BRPA15105Medicare ID - Type Unspecified