1386070837 NPI number — MISS ELENA E GORBUNOVA M.S., LIC.AC, PA-C

Table of content: MISS ELENA E GORBUNOVA M.S., LIC.AC, PA-C (NPI 1386070837)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386070837 NPI number — MISS ELENA E GORBUNOVA M.S., LIC.AC, PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GORBUNOVA
Provider First Name:
ELENA
Provider Middle Name:
E
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
M.S., LIC.AC, PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386070837
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/16/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2721 NE 53RD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIGHTHOUSE POINT
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33064-7847
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-416-7091
Provider Business Mailing Address Fax Number:
561-245-7217

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2061 NW BOCA RATON BLVD
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
BOCA RATON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33431-7411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-245-7217
Provider Business Practice Location Address Fax Number:
561-245-7217
Provider Enumeration Date:
09/16/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  AP3265 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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