Provider Demographics
NPI:1184624801
Name:BORREGARD, SUSAN ELAINE (PA)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:ELAINE
Last Name:BORREGARD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MRS
Other - First Name:SUSAN
Other - Middle Name:ELAINE
Other - Last Name:PIETROWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1200 W WHITE RIVER BLVD
Mailing Address - Street 2:RCS PROVIDER ENROLLMENT
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-4988
Mailing Address - Country:US
Mailing Address - Phone:765-254-4009
Mailing Address - Fax:
Practice Address - Street 1:2525 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-3421
Practice Address - Country:US
Practice Address - Phone:765-289-5420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000623A363A00000X, 363AS0400X
IL085001844363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000826050OtherBCBS
IL970029241Medicare PIN
INP01218025Medicare PIN
INP00729648Medicare PIN
IL970029243Medicare PIN
ILL95166Medicare PIN
ILS26651Medicare UPIN
IN1041009Medicare PIN