Provider Demographics
NPI:1114342722
Name:BRODA, JACQUELINE GUARINO (PA-C)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:GUARINO
Last Name:BRODA
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 1:6621 FANNIN ST
Mailing Address - Street 2:MC 1-1410
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2303
Mailing Address - Country:US
Mailing Address - Phone:713-240-7259
Mailing Address - Fax:
Practice Address - Street 1:6621 FANNIN ST
Practice Address - Street 2:MC 1-1410
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2303
Practice Address - Country:US
Practice Address - Phone:713-240-7259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-19
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical