Provider Demographics
NPI:1194953000
Name:BROSE, AMY ELIZABETH (PA-C)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:ELIZABETH
Last Name:BROSE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 300
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-0300
Mailing Address - Country:US
Mailing Address - Phone:717-270-7780
Mailing Address - Fax:717-274-9746
Practice Address - Street 1:101 FAIRVIEW CIR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-9581
Practice Address - Country:US
Practice Address - Phone:717-279-7303
Practice Address - Fax:717-279-7471
Is Sole Proprietor?:No
Enumeration Date:2009-06-30
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053896363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA331045PUDMedicare PIN