Provider Demographics
NPI:1073672481
Name:BROBERG, CHARLES A (DC, PA,)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:A
Last Name:BROBERG
Suffix:
Gender:M
Credentials:DC, PA,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 W 22ND ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-1521
Mailing Address - Country:US
Mailing Address - Phone:605-312-1000
Mailing Address - Fax:605-312-6100
Practice Address - Street 1:1600 W 22ND ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1521
Practice Address - Country:US
Practice Address - Phone:605-312-1000
Practice Address - Fax:605-312-1001
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0922363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7604240Medicaid
SD0005375OtherBCBS
NDBR021953OtherBCBS
S5375Medicare ID - Type Unspecified
SD7604240Medicaid