Provider Demographics
NPI:1427316280
Name:BRODEGARD, MANDY MARIE
Entity type:Individual
Prefix:MS
First Name:MANDY
Middle Name:MARIE
Last Name:BRODEGARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MANDY
Other - Middle Name:MARIE
Other - Last Name:FOOTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:235 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89503-4548
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:235 W 6TH ST
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-4548
Practice Address - Country:US
Practice Address - Phone:775-770-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-30
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant