MEDICARE: WAYNE BROBERG PT

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	225100000X	Physical Therapist		CA

General Provider Information

NPI Number	:	1982793477
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WAYNE BROBERG PT

Provider Business Mailing Address
First Line	:	6065 MERIDIAN AVE
Second Line	:	STE 70
City	:	SAN JOSE
State	:	CA
Zip	:	95120-2772
Country	:	US
Telephone Number	:	408-927-0871
Fax Number	:	408-927-0891

Provider Business Practice Location Address
First Line	:	6065 MERIDIAN AVE
Second Line	:	STE 70
City	:	SAN JOSE
State	:	CA
Zip	:	95120-2772
Country	:	US
Telephone Number	:	408-927-0871
Fax Number	:	408-927-0891

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

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	12/13/2017

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