Basic Information
| Provider Information | |||||||||
| NPI: | 1952495327 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BORGESON | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26666 | ||||||||
| Address2: | PHS PROVIDER ENROLLMENT | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871256666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059236770 | ||||||||
| FaxNumber: | 5059235354 | ||||||||
| Practice Location | |||||||||
| Address1: | 4005 HIGH RESORT BLVD SE | ||||||||
| Address2: | PMG HIGH RESORT 4005 | ||||||||
| City: | RIO RANCHO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871245906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054626000 | ||||||||
| FaxNumber: | 5054628472 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 03/24/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 84149 | NM | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 34405 | 05 | NM | MEDICAID |