Provider Demographics
NPI:1558381616
Name:BROEKHUIZEN, DANIEL A (NP)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:A
Last Name:BROEKHUIZEN
Suffix:
Gender:M
Credentials:NP
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:6626 E. 75TH STREET
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:765-298-4449
Mailing Address - Fax:765-298-4950
Practice Address - Street 1:1629 MEDICAL ARTS BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46011-3454
Practice Address - Country:US
Practice Address - Phone:765-298-5439
Practice Address - Fax:765-298-4920
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2015-03-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN71000421A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200217190Medicaid
IN200217190Medicaid