MEDICARE: MRS. JAMI J BROKAW CPT

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	174400000X	Specialist	652729	NM

General Provider Information

NPI Number	:	1306088554
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JAMI J BROKAW CPT

Provider Business Mailing Address
First Line	:	336 ADAMS ST SE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87108-2837
Country	:	US
Telephone Number	:	505-268-1231
Fax Number	:	505-268-1968

Provider Business Practice Location Address
First Line	:	336 ADAMS ST SE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87108-2837
Country	:	US
Telephone Number	:	505-268-1231
Fax Number	:	505-268-1968

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

Provider Enumeration Date	:	04/02/2009
Last Update Date	:	04/02/2009

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