Provider Demographics
NPI:1194967281
Name:BORDEGARAY, NICHOLE PATRICIA (MD)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:PATRICIA
Last Name:BORDEGARAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NICHOLE
Other - Middle Name:PATRICIA
Other - Last Name:BURKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:800 BRADBURY DR SE STE 116
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4310
Mailing Address - Country:US
Mailing Address - Phone:505-272-1476
Mailing Address - Fax:
Practice Address - Street 1:9655 S DIXIE HWY STE 111
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33156-2813
Practice Address - Country:US
Practice Address - Phone:302-740-0823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-03
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 115102207L00000X
390200000X
NMMD2016-0230207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program