Provider Demographics
NPI:1518302603
Name:BROCKWAY, KRISTIN DANAE (MD)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:DANAE
Last Name:BROCKWAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26310 EMERY RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44128-5735
Mailing Address - Country:US
Mailing Address - Phone:216-791-3580
Mailing Address - Fax:216-378-6236
Practice Address - Street 1:1125 7TH AVE
Practice Address - Street 2:
Practice Address - City:BEAVER FALLS
Practice Address - State:PA
Practice Address - Zip Code:15010-4426
Practice Address - Country:US
Practice Address - Phone:724-773-8900
Practice Address - Fax:724-770-7947
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-03
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT203740207Q00000X
OH35.129188207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine