Provider Demographics
NPI:1316605017
Name:MCBROOM, JARED RANDAL (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:RANDAL
Last Name:MCBROOM
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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Mailing Address - Street 1:1416 STONEWAY DR NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-6046
Mailing Address - Country:US
Mailing Address - Phone:505-364-6915
Mailing Address - Fax:
Practice Address - Street 1:2211 LOMAS BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2719
Practice Address - Country:US
Practice Address - Phone:505-272-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-30
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2021-0110363A00000X, 207P00000X
COPA.0008578363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine