Provider Demographics
NPI:1104224062
Name:BORST, NICHOLE RAE (PA-C)
Entity type:Individual
Prefix:MISS
First Name:NICHOLE
Middle Name:RAE
Last Name:BORST
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 14TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:MT
Mailing Address - Zip Code:59270-3521
Mailing Address - Country:US
Mailing Address - Phone:406-488-2100
Mailing Address - Fax:
Practice Address - Street 1:214 14TH AVE SW
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:MT
Practice Address - Zip Code:59270-3521
Practice Address - Country:US
Practice Address - Phone:406-488-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-09
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTATR-LAT-LIC-372255A2300X
390200000X
MT91635363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program