Individual
MS. TAEJA BROADWATER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PA-C
Taxonomy
Speciality
Code
Description
License number
State
163WM0705X
Medical-Surgical Registered Nurse
R185137
MD
363AS0400X
Surgical Physician Assistant
Primary
MAO55689
PA
Other
Enumeration date
05/18/2009
Last updated
09/27/2013
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