Healthcare Provider Details

I. General information

NPI: 1073447330
Provider Name (Legal Business Name): CHASE VICTORIA BROOME PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2026
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2902 224TH ST
LAKE CITY FL
32024-2504
US

IV. Provider business mailing address

2902 224TH ST
LAKE CITY FL
32024-2504
US

V. Phone/Fax

Practice location:
  • Phone: 386-365-2704
  • Fax:
Mailing address:
  • Phone: 386-365-2704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9121799
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: