MEDICARE: AMY BROADWATER P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	MA002774L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194753327
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY BROADWATER P.A.

Provider Business Mailing Address
First Line	:	236 ELM DR STE 101
Second Line	:
City	:	WAYNESBURG
State	:	PA
Zip	:	15370-8265
Country	:	US
Telephone Number	:	724-627-0926
Fax Number	:	724-627-0812

Provider Business Practice Location Address
First Line	:	236 ELM DR STE 101
Second Line	:
City	:	WAYNESBURG
State	:	PA
Zip	:	15370-8265
Country	:	US
Telephone Number	:	724-627-0926
Fax Number	:	724-627-0812

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/28/2006
Last Update Date	:	09/20/2024

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