Provider Demographics
NPI:1407107865
Name:BROKAW, SANDRA KATHRYN (PTA)
Entity Type:Individual
Prefix:MISS
First Name:SANDRA
Middle Name:KATHRYN
Last Name:BROKAW
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2225 GRAND AVE APT 104
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-5316
Mailing Address - Country:US
Mailing Address - Phone:515-991-4261
Mailing Address - Fax:
Practice Address - Street 1:708 S JEFFERSON WAY
Practice Address - Street 2:
Practice Address - City:INDIANOLA
Practice Address - State:IA
Practice Address - Zip Code:50125-3216
Practice Address - Country:US
Practice Address - Phone:515-962-2555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-26
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA004802225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA004802OtherSTATE OF IOWA