Healthcare Provider Details

I. General information

NPI: 1003876483
Provider Name (Legal Business Name): DIANN ELLEN BORTHWICK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 05/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9129 PRELOG LN
KIRTLAND OH
44094-5182
US

IV. Provider business mailing address

9129 PRELOG LN
KIRTLAND OH
44094-5182
US

V. Phone/Fax

Practice location:
  • Phone: 440-256-9129
  • Fax:
Mailing address:
  • Phone: 440-256-9129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50001360
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: