Provider Demographics
NPI:1316159072
Name:BROKAW, BRUCE (PA-C)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:BROKAW
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 1:400 CAPTAIN THOMAS RD
Mailing Address - Street 2:WELLS
Mailing Address - City:MAINE
Mailing Address - State:ME
Mailing Address - Zip Code:04090
Mailing Address - Country:US
Mailing Address - Phone:603-740-3293
Mailing Address - Fax:
Practice Address - Street 1:400 CAPTAIN THOMAS ROAD
Practice Address - Street 2:
Practice Address - City:WELLS
Practice Address - State:ME
Practice Address - Zip Code:04090-7552
Practice Address - Country:US
Practice Address - Phone:603-740-3293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0170363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical