Provider Demographics
NPI:1467837088
Name:BROTTEM, CRNA, JOSEPH
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:BROTTEM, CRNA
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:PO BOX 5587
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77726-5587
Mailing Address - Country:US
Mailing Address - Phone:409-838-5214
Mailing Address - Fax:
Practice Address - Street 1:755 N 11TH ST
Practice Address - Street 2:SUITE P3600
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1500
Practice Address - Country:US
Practice Address - Phone:409-838-5214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-24
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP128408367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered