Provider Demographics
NPI:1669579850
Name:BORK, KAYDEE (PAC)
Entity type:Individual
Prefix:
First Name:KAYDEE
Middle Name:
Last Name:BORK
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:KAYDEE
Other - Middle Name:
Other - Last Name:ONEILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:11515 EL CAMINO REAL
Mailing Address - Street 2:SUIT 150
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130
Mailing Address - Country:US
Mailing Address - Phone:858-720-1440
Mailing Address - Fax:858-509-7738
Practice Address - Street 1:11515 EL CAMINO REAL
Practice Address - Street 2:SUIT 150
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130
Practice Address - Country:US
Practice Address - Phone:858-720-1440
Practice Address - Fax:858-509-7738
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WPA14448AMedicare ID - Type Unspecified