Provider Demographics
NPI:1538308390
Name:BROADT, WAYNE J (PT)
Entity Type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:J
Last Name:BROADT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 S CLOSNER BLVD
Mailing Address - Street 2:SUITE: B
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78539-5617
Mailing Address - Country:US
Mailing Address - Phone:956-287-2006
Mailing Address - Fax:956-287-2016
Practice Address - Street 1:920 S CLOSNER BLVD
Practice Address - Street 2:SUITE: B
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-5617
Practice Address - Country:US
Practice Address - Phone:956-287-2006
Practice Address - Fax:956-287-2016
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-18
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1177760225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX178709501Medicaid
TX00994ZOtherMEDICARE PART B
TX0046NNOtherBCBS
TX676617OtherMEDICARE PART A