MEDICARE: BROOKLYNN ASHLEY BOULWARE PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1154095727
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BROOKLYNN ASHLEY BOULWARE PA-C

Provider Business Mailing Address
First Line	:	1840 SOUTH STREET, 2ND FLOOR
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19146-7422
Country	:	US
Telephone Number	:	215-893-2240
Fax Number	:

Provider Business Practice Location Address
First Line	:	1840 SOUTH STREET, 2ND FLOOR
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19146-7422
Country	:	US
Telephone Number	:	215-893-2240
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/05/2021
Last Update Date	:	06/08/2023

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