Provider Demographics
NPI:1124120126
Name:BORUTA, VICKI
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:
Last Name:BORUTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 BLAIR MILL RD
Mailing Address - Street 2:SUITE 8
Mailing Address - City:WILLOW GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19090-1041
Mailing Address - Country:US
Mailing Address - Phone:215-957-9250
Mailing Address - Fax:215-957-9254
Practice Address - Street 1:2701 BLAIR MILL RD
Practice Address - Street 2:SUITE 8
Practice Address - City:WILLOW GROVE
Practice Address - State:PA
Practice Address - Zip Code:19090-1041
Practice Address - Country:US
Practice Address - Phone:215-957-9250
Practice Address - Fax:215-957-9254
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA000872-L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
30702Medicare UPIN