Healthcare Provider Details

I. General information

NPI: 1346508835
Provider Name (Legal Business Name): EDVIGE JANE GUSMORINO BORDEN CST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2012
Last Update Date: 04/27/2020
Certification Date: 04/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11914 ASTORIA BLVD 125
HOUSTON TX
77089-6064
US

IV. Provider business mailing address

3006 AVANTI CT
PEARLAND TX
77584-4917
US

V. Phone/Fax

Practice location:
  • Phone: 281-482-5300
  • Fax:
Mailing address:
  • Phone: 281-413-4978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number125878
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License NumberSA00693
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: