Provider Demographics
NPI:1922972793
Name:BUBOLZ, BROOKE ELIZABETH
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:ELIZABETH
Last Name:BUBOLZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:456 S WAVERLY RD
Mailing Address - Street 2:
Mailing Address - City:EATON RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:48827-9299
Mailing Address - Country:US
Mailing Address - Phone:517-614-8344
Mailing Address - Fax:
Practice Address - Street 1:456 S WAVERLY RD
Practice Address - Street 2:
Practice Address - City:EATON RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:48827-9299
Practice Address - Country:US
Practice Address - Phone:517-614-8344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-03
Last Update Date:2025-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant