=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144762238
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PATHWAYS MEDICAL PARTNERS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2016
-----------------------------------------------------
Last Update Date | 01/10/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1700 E RIVER RD #65177
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85728-5177
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-635-9103
-----------------------------------------------------
Fax | 520-336-9179
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 65177
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85728-5177
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-635-9103
-----------------------------------------------------
Fax | 520-336-9179
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | IVAN A BORBON
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 520-635-9103
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 23543
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------