Provider Demographics
NPI:1114241015
Name:BROSTROM, JAMES
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:BROSTROM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 LAURA LN
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-2808
Mailing Address - Country:US
Mailing Address - Phone:262-896-9661
Mailing Address - Fax:262-896-9662
Practice Address - Street 1:1900 LAURA LN
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-2808
Practice Address - Country:US
Practice Address - Phone:262-896-9661
Practice Address - Fax:262-896-9662
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-22
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor