Healthcare Provider Details

I. General information

NPI: 1912405531
Provider Name (Legal Business Name): MARYANNA KATHRYN BROCKMAN PA-C, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2018
Last Update Date: 08/19/2025
Certification Date: 08/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 N BREIEL BLVD
MIDDLETOWN OH
45042-3807
US

IV. Provider business mailing address

30 CLEVENGER CT
SPRINGBORO OH
45066-7429
US

V. Phone/Fax

Practice location:
  • Phone: 513-424-7711
  • Fax:
Mailing address:
  • Phone: 937-422-3449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.007758RX
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: