Provider Demographics
NPI:1528200623
Name:BRONKHORST, ARIE J (CO,LO,LPA)
Entity Type:Individual
Prefix:
First Name:ARIE
Middle Name:J
Last Name:BRONKHORST
Suffix:
Gender:M
Credentials:CO,LO,LPA
Other - Prefix:
Other - First Name:BUD
Other - Middle Name:
Other - Last Name:BRONKHORST
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CO,LO,LPA
Mailing Address - Street 1:1301 BARBARA JORDAN BLVD STE 306
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-3080
Mailing Address - Country:US
Mailing Address - Phone:512-459-0011
Mailing Address - Fax:512-459-9522
Practice Address - Street 1:1301 BARBARA JORDAN BLVD STE 306
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723-3080
Practice Address - Country:US
Practice Address - Phone:512-459-0011
Practice Address - Fax:512-459-9522
Is Sole Proprietor?:No
Enumeration Date:2009-04-03
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX159222Z00000X
TX1139363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX79427303Medicaid