Provider Demographics
NPI:1285016998
Name:BROSNAN, TANYA KOFOED (PA)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:KOFOED
Last Name:BROSNAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22210
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94623-2210
Mailing Address - Country:US
Mailing Address - Phone:510-535-4000
Mailing Address - Fax:
Practice Address - Street 1:7901 STONERIDGE DR
Practice Address - Street 2:SUITE 230
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94588-3677
Practice Address - Country:US
Practice Address - Phone:925-277-1123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-18
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA52463363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical