Provider Demographics
NPI:1083194732
Name:BRODSTON, SHIRLEY HUGUES (APRN)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:HUGUES
Last Name:BRODSTON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:SHIRLEY
Other - Middle Name:
Other - Last Name:HUGUES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:325 DISTEL CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:800-972-5547
Mailing Address - Fax:
Practice Address - Street 1:685 COLEMAN AVE STE 20
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95110-2011
Practice Address - Country:US
Practice Address - Phone:800-972-5547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95011771363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95011771Medicaid