Provider Demographics
NPI:1437828936
Name:BROMIR, ANDREW (PA-C)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:BROMIR
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4706 HARDING RD
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-3159
Mailing Address - Country:US
Mailing Address - Phone:815-354-9546
Mailing Address - Fax:
Practice Address - Street 1:13250 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53177-1516
Practice Address - Country:US
Practice Address - Phone:262-799-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-08
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100260723Medicaid