Healthcare Provider Details

I. General information

NPI: 1376258517
Provider Name (Legal Business Name): SHAJEDA BINTE BORHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2023
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 S MAIN ST STE B
LAS CRUCES NM
88005-2946
US

IV. Provider business mailing address

PO BOX 13129
SALEM OR
97309-1129
US

V. Phone/Fax

Practice location:
  • Phone: 575-525-4000
  • Fax:
Mailing address:
  • Phone: 503-391-1110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2022-1188
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD219162
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: