Provider Demographics
NPI:1275835597
Name:BROAD, JAN MICHAEL (NP-C)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:MICHAEL
Last Name:BROAD
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 SANDPIPER PL
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-5390
Mailing Address - Country:US
Mailing Address - Phone:715-392-9192
Mailing Address - Fax:
Practice Address - Street 1:6 SANDPIPER PL
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-5390
Practice Address - Country:US
Practice Address - Phone:715-392-9192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-18
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR134618-7363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily