MEDICARE: JANE D BROCKHAUSEN 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	363AM0700X	Medical Physician Assistant	0001833	CO

General Provider Information

NPI Number	:	1770538159
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JANE D BROCKHAUSEN PA-C

Provider Business Mailing Address
First Line	:	5799 STETSON HILLS BLVD STE 100
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80917-4223
Country	:	US
Telephone Number	:	719-471-2273
Fax Number	:	719-380-0228

Provider Business Practice Location Address
First Line	:	5799 STETSON HILLS BLVD STE 100
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80917-4223
Country	:	US
Telephone Number	:	719-471-2273
Fax Number	:	719-380-0228

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

Provider Enumeration Date	:	05/23/2006
Last Update Date	:	07/28/2017

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