Provider Demographics
NPI:1154095727
Name:BOULWARE, BROOKLYNN ASHLEY (PA-C)
Entity Type:Individual
Prefix:
First Name:BROOKLYNN
Middle Name:ASHLEY
Last Name:BOULWARE
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 1:1840 SOUTH STREET, 2ND FLOOR
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-7422
Mailing Address - Country:US
Mailing Address - Phone:215-893-2240
Mailing Address - Fax:
Practice Address - Street 1:1840 SOUTH STREET, 2ND FLOOR
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19146-7422
Practice Address - Country:US
Practice Address - Phone:215-893-2240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-05
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant