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NPI Code Detail

MEDICARE: WESLEY W BROEDER PA-C

MEDICARE: WESLEY W BROEDER 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
1363A00000XPhysician Assistant0657SD

General Provider Information

NPI Number : 1598952822
Entity Type Code : Individual
Provider Name (Legal Business Name) : WESLEY W BROEDER PA-C
Provider Business Mailing Address
First Line : 353 FAIRMONT BLVD
Second Line : ATTEN MEDICAL STAFF SERVICES
City : RAPID CITY
State : SD
Zip : 57701-6000
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 2479 E COLORADO BLVD
Second Line :
City : SPEARFISH
State : SD
Zip : 57783-3204
Country : US
Telephone Number : 605-644-4460
Fax Number : 605-644-4461
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/01/2007
Last Update Date : 02/05/2013

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Directions to “ WESLEY W BROEDER PA-C” Practice Location

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