Provider Demographics
NPI:1073847000
Name:BROCKMAN, ELIZABETH ASHLEY (PAC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ASHLEY
Last Name:BROCKMAN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 LANTANA RD STE 202
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-1903
Mailing Address - Country:US
Mailing Address - Phone:931-484-5141
Mailing Address - Fax:
Practice Address - Street 1:100 LANTANA RD STE 202
Practice Address - Street 2:
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-1903
Practice Address - Country:US
Practice Address - Phone:931-484-5141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-23
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105186363A00000X
TN3593363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ044474Medicaid