Healthcare Provider Details

I. General information

NPI: 1194753327
Provider Name (Legal Business Name): AMY BROADWATER P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 09/20/2024
Certification Date: 09/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

236 ELM DR STE 101
WAYNESBURG PA
15370-8265
US

IV. Provider business mailing address

236 ELM DR STE 101
WAYNESBURG PA
15370-8265
US

V. Phone/Fax

Practice location:
  • Phone: 724-627-0926
  • Fax: 724-627-0812
Mailing address:
  • Phone: 724-627-0926
  • Fax: 724-627-0812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA002774L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: