Provider Demographics
NPI:1558469361
Name:BROGAN, CHARLES P (RPAC)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:P
Last Name:BROGAN
Suffix:
Gender:M
Credentials:RPAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 E JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11702-4209
Mailing Address - Country:US
Mailing Address - Phone:631-321-5875
Mailing Address - Fax:631-321-5875
Practice Address - Street 1:32 E JACKSON AVE
Practice Address - Street 2:
Practice Address - City:BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11702-4209
Practice Address - Country:US
Practice Address - Phone:631-321-5875
Practice Address - Fax:631-321-5875
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
0F4421Medicare ID - Type Unspecified
S89586Medicare UPIN