Provider Demographics
NPI:1063127199
Name:BROOME, JOHN EDWARD (PRSS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:EDWARD
Last Name:BROOME
Suffix:
Gender:M
Credentials:PRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13224 SE 202ND RD
Mailing Address - Street 2:
Mailing Address - City:TALIHINA
Mailing Address - State:OK
Mailing Address - Zip Code:74571-5866
Mailing Address - Country:US
Mailing Address - Phone:918-567-7000
Mailing Address - Fax:918-567-2417
Practice Address - Street 1:13224 SE 202ND RD
Practice Address - Street 2:
Practice Address - City:TALIHINA
Practice Address - State:OK
Practice Address - Zip Code:74571-5866
Practice Address - Country:US
Practice Address - Phone:918-567-7000
Practice Address - Fax:918-567-2417
Is Sole Proprietor?:No
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist