Provider Demographics
NPI:1073847000
Name:BROCKMAN, ELIZABETH ASHLEY (PAC)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ASHLEY
Last Name:BROCKMAN
Suffix:
Gender:
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 CLEVELAND ST STE 350
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-2898
Mailing Address - Country:US
Mailing Address - Phone:319-459-7720
Mailing Address - Fax:865-374-2113
Practice Address - Street 1:49 CLEVELAND ST STE 350
Practice Address - Street 2:
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-2898
Practice Address - Country:US
Practice Address - Phone:931-459-7720
Practice Address - Fax:865-374-2113
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-23
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105186363A00000X
TN3593363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ044474Medicaid