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NPI Code Detail

MEDICARE: JESSICA BRODERICK PA-C

MEDICARE: JESSICA BRODERICK 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 Assistant8887GA

General Provider Information

NPI Number : 1700365103
Entity Type Code : Individual
Provider Name (Legal Business Name) : JESSICA BRODERICK PA-C
Provider Business Mailing Address
First Line : PO BOX 636
Second Line :
City : PINE LAKE
State : GA
Zip : 30072-0636
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1000 WHITE ST SW
Second Line :
City : ATLANTA
State : GA
Zip : 30310-2634
Country : US
Telephone Number : 404-616-6000
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/07/2018
Last Update Date : 10/18/2024

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Directions to “ JESSICA BRODERICK PA-C” Practice Location

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