Provider Demographics
NPI:1134869969
Name:BORNHARDT, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:BORNHARDT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 DELSEA DR
Mailing Address - Street 2:
Mailing Address - City:DEPTFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-4101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1410 DELSEA DR
Practice Address - Street 2:
Practice Address - City:DEPTFORD
Practice Address - State:NJ
Practice Address - Zip Code:08096-4101
Practice Address - Country:US
Practice Address - Phone:856-579-8897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-30
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MP00728900363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program