Provider Demographics
NPI:1043620669
Name:BROSIUS, KLA J (CRNP)
Entity Type:Individual
Prefix:
First Name:KLA
Middle Name:J
Last Name:BROSIUS
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 MEMORY LN
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-2231
Mailing Address - Country:US
Mailing Address - Phone:717-264-5211
Mailing Address - Fax:717-264-5418
Practice Address - Street 1:8131 SPYGLASS HILL DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:PA
Practice Address - Zip Code:17222-5500
Practice Address - Country:US
Practice Address - Phone:717-264-5211
Practice Address - Fax:717-264-5418
Is Sole Proprietor?:No
Enumeration Date:2014-05-05
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
PARN703306363L00000X
PASP022125363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
1043620669OtherNPI
PA14672457OtherCAQH
PA103802749Medicaid