Healthcare Provider Details

I. General information

NPI: 1053468199
Provider Name (Legal Business Name): JUSTIN LUKE BOREN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 08/15/2023
Certification Date: 08/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

832 WESTOVER DR STE 200
COLUMBIA TN
38401-4843
US

IV. Provider business mailing address

410 42ND AVE N STE 400
NASHVILLE TN
37209-3658
US

V. Phone/Fax

Practice location:
  • Phone: 931-830-3033
  • Fax: 931-388-3401
Mailing address:
  • Phone: 615-329-7887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1296
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: