Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251X0800X | Physical Therapist - Orthopedic | PT27048 | CA |
NPI | 1043413230 |
---|---|
Provider Name | Ole Christian Borgesen |
First Address | Novato, CA 94947-2985 |
Second Address | Novato, CA 94945-5038 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/06/2007 |
Last Update Date | 21/05/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
PT27048 | PHYSICAL THERAPY LICENSE (01) | CA |