Provider Demographics
NPI:1467988790
Name:BROKAW-MYERS, PAM LYNN (NP)
Entity Type:Individual
Prefix:
First Name:PAM
Middle Name:LYNN
Last Name:BROKAW-MYERS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MRS
Other - First Name:PAM
Other - Middle Name:LYNN
Other - Last Name:MYERS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:500 LINCOLN PARK BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-6410
Mailing Address - Country:US
Mailing Address - Phone:937-531-5020
Mailing Address - Fax:937-298-4385
Practice Address - Street 1:500 LINCOLN PARK BLVD STE 110
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-6410
Practice Address - Country:US
Practice Address - Phone:937-531-5020
Practice Address - Fax:937-298-4385
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-05
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP 020349363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0232002Medicaid