Provider Demographics
NPI:1023530219
Name:BORCHGREVINK, KELBY
Entity type:Individual
Prefix:
First Name:KELBY
Middle Name:
Last Name:BORCHGREVINK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4908 BRAHMA ST
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82718-8503
Mailing Address - Country:US
Mailing Address - Phone:307-257-3417
Mailing Address - Fax:
Practice Address - Street 1:3425 N 1ST ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-6821
Practice Address - Country:US
Practice Address - Phone:559-608-6581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-10
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63438363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant