Provider Demographics
NPI:1073311536
Name:BROADBEAR, CORA (NP)
Entity type:Individual
Prefix:
First Name:CORA
Middle Name:
Last Name:BROADBEAR
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:CORA
Other - Middle Name:
Other - Last Name:HARRISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:21 W SAGE LN
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84780-4906
Mailing Address - Country:US
Mailing Address - Phone:435-773-7747
Mailing Address - Fax:
Practice Address - Street 1:21 W SAGE LN
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:UT
Practice Address - Zip Code:84780-4906
Practice Address - Country:US
Practice Address - Phone:435-773-7747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-03
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7312937-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner