Provider Demographics
NPI:1972552586
Name:BROXTERMAN, ROBERT JOHN (MS, ATC/R)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:JOHN
Last Name:BROXTERMAN
Suffix:
Gender:M
Credentials:MS, ATC/R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 CALIFORNIA AVE W
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-2202
Mailing Address - Country:US
Mailing Address - Phone:651-487-9046
Mailing Address - Fax:
Practice Address - Street 1:4080 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-5604
Practice Address - Country:US
Practice Address - Phone:651-491-5847
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1031174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist