Provider Demographics
NPI:1063894475
Name:SONG, BORAM
Entity type:Individual
Prefix:
First Name:BORAM
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BORAM
Other - Middle Name:
Other - Last Name:SONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:200 GRAND AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-4363
Mailing Address - Country:US
Mailing Address - Phone:201-944-3800
Mailing Address - Fax:201-944-3804
Practice Address - Street 1:200 GRAND AVE STE 201
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-4363
Practice Address - Country:US
Practice Address - Phone:201-944-3800
Practice Address - Fax:201-944-3804
Is Sole Proprietor?:No
Enumeration Date:2015-06-22
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF339122363LF0000X
NJ26NJ00890500363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily