Provider Demographics
NPI:1861417982
Name:BORON, MARY D (CNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:D
Last Name:BORON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4330 W 150TH ST
Mailing Address - Street 2:METROHEALTH OUTPATIENT SURGERY CENTER
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44135-1362
Mailing Address - Country:US
Mailing Address - Phone:216-251-6990
Mailing Address - Fax:
Practice Address - Street 1:4330 W 150TH ST
Practice Address - Street 2:METROHEALTH OUTPATIENT SURGERY CENTER
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44135-1362
Practice Address - Country:US
Practice Address - Phone:216-251-6990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP01401363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2382032Medicaid
OH27460006500OtherBWC
OHP81640Medicare UPIN
OHBONP30061Medicare PIN
OH2382032Medicaid