Healthcare Provider Details

I. General information

NPI: 1063172724
Provider Name (Legal Business Name): REBEKA BROUILLARD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2021
Last Update Date: 12/22/2021
Certification Date: 12/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3531 LITTLE RD
TRINITY FL
34655-1811
US

IV. Provider business mailing address

38135 MARKET SQ
ZEPHYRHILLS FL
33542-7505
US

V. Phone/Fax

Practice location:
  • Phone: 727-375-1548
  • Fax: 727-375-1557
Mailing address:
  • Phone: 352-567-0188
  • Fax: 813-355-5101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9115360
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: