Provider Demographics
NPI:1427119437
Name:BORDEN, BRIAN JOSEPH (PT)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:JOSEPH
Last Name:BORDEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 SOUTHPARK BLVD STE B201
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5159
Mailing Address - Country:US
Mailing Address - Phone:904-824-1636
Mailing Address - Fax:
Practice Address - Street 1:1361 13TH AVE S STE 160
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3235
Practice Address - Country:US
Practice Address - Phone:904-339-8406
Practice Address - Fax:904-339-8407
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT22603225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT22603OtherPT LICENSE