Basic Information
| Provider Information | |||||||||
| NPI: | 1467776278 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BORGMAN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCGUIRE | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | ANN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 44008 | ||||||||
| Address2: | UFJP - PROVIDER ENROLLMENT | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322314008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042443199 | ||||||||
| FaxNumber: | 9042443425 | ||||||||
| Practice Location | |||||||||
| Address1: | 841 PRUDENTIAL DR | ||||||||
| Address2: | UFJAX - PEDIATRIC CARDIOLOGY | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046334110 | ||||||||
| FaxNumber: | 9046334111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2010 | ||||||||
| LastUpdateDate: | 05/26/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9101430 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.