1043406481 NPI number — BRANDI L. BROUGHTON PHYSICIAN ASSISTANT

Table of content: BRANDI L. BROUGHTON PHYSICIAN ASSISTANT (NPI 1043406481)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043406481 NPI number — BRANDI L. BROUGHTON PHYSICIAN ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROUGHTON
Provider First Name:
BRANDI
Provider Middle Name:
L.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHYSICIAN ASSISTANT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043406481
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/16/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4651 VAN DYKE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUTZ
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33558-4880
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-321-1786
Provider Business Mailing Address Fax Number:
813-321-1787

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12900 CORTEZ BLVD STE 205
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKSVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34613-4898
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-321-1786
Provider Business Practice Location Address Fax Number:
813-321-1787
Provider Enumeration Date:
09/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA 9104237 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PA9104237 . This is a "LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 102702200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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