MEDICARE: TONI ANNETTE BORK CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	AP02316	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063457885
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TONI ANNETTE BORK CRNA

Provider Business Mailing Address
First Line	:	1057 PAUL MAILLARD RD
Second Line	:
City	:	LULING
State	:	LA
Zip	:	70070-4349
Country	:	US
Telephone Number	:	985-785-6242
Fax Number	:

Provider Business Practice Location Address
First Line	:	1057 PAUL MAILLARD RD
Second Line	:
City	:	LULING
State	:	LA
Zip	:	70070-4349
Country	:	US
Telephone Number	:	985-785-6242
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/17/2006
Last Update Date	:	05/25/2016

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