Provider Demographics
NPI:1275075152
Name:BROCKMAN, MICHAEL P
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:P
Last Name:BROCKMAN
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 1:5348 LAMME RD
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-3215
Mailing Address - Country:US
Mailing Address - Phone:937-534-4651
Mailing Address - Fax:937-522-8799
Practice Address - Street 1:5348 LAMME RD
Practice Address - Street 2:
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439-3215
Practice Address - Country:US
Practice Address - Phone:937-534-4651
Practice Address - Fax:937-522-8799
Is Sole Proprietor?:No
Enumeration Date:2016-11-09
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.024158363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0342029Medicaid
OHH709731OtherMEDICARE