Provider Demographics
NPI:1063074037
Name:BROMAGEN, TABITHA (PTA)
Entity type:Individual
Prefix:MRS
First Name:TABITHA
Middle Name:
Last Name:BROMAGEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 HACKBERRY ST
Mailing Address - Street 2:
Mailing Address - City:BENNET
Mailing Address - State:NE
Mailing Address - Zip Code:68317-2510
Mailing Address - Country:US
Mailing Address - Phone:402-304-0022
Mailing Address - Fax:
Practice Address - Street 1:1550 S CODDINGTON AVE STE C
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68522-4402
Practice Address - Country:US
Practice Address - Phone:402-423-0303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-30
Last Update Date:2019-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1484225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant