MEDICARE: MARK JAMES BROXTERMAN

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	225400000X	Rehabilitation Practitioner

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1841583986
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK JAMES BROXTERMAN

Provider Business Mailing Address
First Line	:	8107 CIMARRON MEADOWS WAY
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89147-5055
Country	:	US
Telephone Number	:	702-429-2654
Fax Number	:	702-221-4275

Provider Business Practice Location Address
First Line	:	8107 CIMARRON MEADOWS WAY
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89147-5055
Country	:	US
Telephone Number	:	702-429-2654
Fax Number	:	702-221-4275

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

Provider Enumeration Date	:	05/23/2011
Last Update Date	:	06/07/2011

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