Provider Demographics
NPI:1194820555
Name:BRODERICK, ANTHONY R (NP)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:R
Last Name:BRODERICK
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2003 KOOTENAI HEALTH WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-6051
Mailing Address - Country:US
Mailing Address - Phone:208-625-5085
Mailing Address - Fax:208-625-5731
Practice Address - Street 1:2003 KOOTENAI HEALTH WAY
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-6051
Practice Address - Country:US
Practice Address - Phone:208-625-5185
Practice Address - Fax:208-625-6892
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP675A363L00000X
IDRN33608363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDNP675EOtherSTATE LICENSE #