Healthcare Provider Details

I. General information

NPI: 1053288480
Provider Name (Legal Business Name): LANDON BROOME PA STUDENT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2025
Last Update Date: 10/21/2025
Certification Date: 10/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 N UNIVERSITY BLVD
MOBILE AL
36688-3053
US

IV. Provider business mailing address

375 HILLCREST RD APT P205
MOBILE AL
36608-3887
US

V. Phone/Fax

Practice location:
  • Phone: 251-460-6101
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: