Provider Demographics
NPI:1700462041
Name:CARBAJAL-BORJA, BRYAN I
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:CARBAJAL-BORJA
Suffix:I
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 1:3612 36TH AVE
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11106-1334
Mailing Address - Country:US
Mailing Address - Phone:718-819-8623
Mailing Address - Fax:347-448-6213
Practice Address - Street 1:3612 36TH AVE
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11106-1334
Practice Address - Country:US
Practice Address - Phone:718-819-8623
Practice Address - Fax:347-448-6213
Is Sole Proprietor?:No
Enumeration Date:2021-03-18
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator