MEDICARE: JACOB BROCKMANN 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	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician	9130	AZ

General Provider Information

NPI Number	:	1861121212
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB BROCKMANN PA-C

Provider Business Mailing Address
First Line	:	1423 N POMEROY
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85201-2714
Country	:	US
Telephone Number	:	707-978-9002
Fax Number	:

Provider Business Practice Location Address
First Line	:	18700 N 64TH DR STE 205
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85308-7112
Country	:	US
Telephone Number	:	602-277-6211
Fax Number	:

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

Provider Enumeration Date	:	06/09/2022
Last Update Date	:	06/09/2022

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Directions to “ JACOB BROCKMANN PA-C” Practice Location

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