Provider Demographics
NPI:1427428937
Name:BORDONARO, TINA
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:BORDONARO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:NICOLE
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:11350 MCCORMICK RD
Mailing Address - Street 2:EXECUTIVE PLAZA 1, SUITE 501
Mailing Address - City:HUNT VALLEY
Mailing Address - State:MD
Mailing Address - Zip Code:21031
Mailing Address - Country:US
Mailing Address - Phone:410-329-1071
Mailing Address - Fax:410-329-1054
Practice Address - Street 1:920 N SHENANDOAH AVE STE 101
Practice Address - Street 2:
Practice Address - City:FRONT ROYAL
Practice Address - State:VA
Practice Address - Zip Code:22630
Practice Address - Country:US
Practice Address - Phone:540-551-5564
Practice Address - Fax:703-642-1876
Is Sole Proprietor?:No
Enumeration Date:2015-09-28
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0005787363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical