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General NPI Number Information
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NPI Number | 1114152329
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Entity Type | Individual
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Provider Name | TAEJA BROADWATER PA-C
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Gender | Female
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Dates
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Enumeration Date | 05/18/2009
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Last Update Date | 09/27/2013
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Provider Practice Location Address
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Address Line | GEISINGER MEDICAL CTR 100 NORTH ACADEMY DRIVE
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City | DANVILLE
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State | PA
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Zip | 17822-0001
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Country | US
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Telephone | 570-271-5555
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Fax |
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Provider Business Mailing Address
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Address Line | 1015 CLIFTON DR
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City | BLOOMSBURG
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State | PA
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Zip | 17815-3083
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Country | US
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Telephone | 304-673-9476
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163WM0705X
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Taxonomy Name | Medical-Surgical Registered Nurse
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License Number | R185137
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | MAO55689
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License Number State | PA
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