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General NPI Number Information
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NPI Number | 1891352928
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Entity Type | Individual
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Provider Name | NICOLE M BRODEN MD
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Gender | Female
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Dates
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Enumeration Date | 05/23/2019
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Last Update Date | 06/26/2025
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Provider Practice Location Address
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Address Line | 3 RIVERSIDE CIR
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City | ROANOKE
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State | VA
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Zip | 24016-4955
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Country | US
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Telephone | 540-224-5170
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Fax |
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Provider Business Mailing Address
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Address Line | 1441 N 12TH ST FL 1
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City | PHOENIX
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State | AZ
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Zip | 85006-2837
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Country | US
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Telephone | 602-521-5981
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Fax | 602-521-5981
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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 | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 101284289
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 0101284289
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License Number State | VA
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