Healthcare Provider Details

I. General information

NPI: 1366780033
Provider Name (Legal Business Name): JUSTIN WAYNE BORDEAUX PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2013
Last Update Date: 05/18/2023
Certification Date: 05/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 US 1 HWY STE 100
YOUNGSVILLE NC
27596-7873
US

IV. Provider business mailing address

3762 DURHAM RD A
ROXBORO NC
27573-2741
US

V. Phone/Fax

Practice location:
  • Phone: 919-562-2340
  • Fax: 919-562-2315
Mailing address:
  • Phone: 336-330-0400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-04057
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0010-04057
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: