Provider Demographics
NPI:1114152329
Name:BROADWATER, TAEJA (PA-C)
Entity Type:Individual
Prefix:MS
First Name:TAEJA
Middle Name:
Last Name:BROADWATER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 CLIFTON DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815-3083
Mailing Address - Country:US
Mailing Address - Phone:304-673-9476
Mailing Address - Fax:
Practice Address - Street 1:GEISINGER MEDICAL CTR
Practice Address - Street 2:100 NORTH ACADEMY DRIVE
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17822-0001
Practice Address - Country:US
Practice Address - Phone:570-271-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-18
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR185137163WM0705X
PAMAO55689363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical