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General NPI Number Information
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NPI Number | 1912405531
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Entity Type | Individual
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Provider Name | MARYANNA KATHRYN BROCKMAN PA-C, ATC
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Gender | Female
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Dates
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Enumeration Date | 01/29/2018
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Last Update Date | 08/19/2025
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Provider Practice Location Address
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Address Line | 275 N BREIEL BLVD
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City | MIDDLETOWN
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State | OH
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Zip | 45042-3807
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Country | US
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Telephone | 513-424-7711
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Fax |
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Provider Business Mailing Address
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Address Line | 30 CLEVENGER CT
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City | SPRINGBORO
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State | OH
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Zip | 45066-7429
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Country | US
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Telephone | 937-422-3449
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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 | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 50.007758RX
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License Number State | OH
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