Provider Demographics
NPI:1215290416
Name:BROPHY, SHAD W (PA-C)
Entity type:Individual
Prefix:
First Name:SHAD
Middle Name:W
Last Name:BROPHY
Suffix:
Gender:M
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 1:30 7TH ST W
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-4335
Mailing Address - Country:US
Mailing Address - Phone:701-456-4000
Mailing Address - Fax:701-456-4800
Practice Address - Street 1:227 16TH ST W
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-4675
Practice Address - Country:US
Practice Address - Phone:701-227-7900
Practice Address - Fax:701-227-7985
Is Sole Proprietor?:No
Enumeration Date:2012-06-21
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT102455363A00000X
NDPAC0482363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant