Provider Demographics
NPI:1215696166
Name:BORDEN, ALEXANDER DMITRY (PTA)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:DMITRY
Last Name:BORDEN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4217 AVENT FERRY RD APT 1
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27606-4812
Mailing Address - Country:US
Mailing Address - Phone:984-244-4954
Mailing Address - Fax:
Practice Address - Street 1:11081 FOREST PINES DR STE 112
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27614-7656
Practice Address - Country:US
Practice Address - Phone:919-348-5719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA7272225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant