Provider Demographics
NPI:1558546267
Name:MCBROOM, DENISE MICHELLE (PA)
Entity Type:Individual
Prefix:MRS
First Name:DENISE
Middle Name:MICHELLE
Last Name:MCBROOM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 E. 72ND STREET
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-4913
Mailing Address - Country:US
Mailing Address - Phone:912-819-7878
Mailing Address - Fax:912-819-5044
Practice Address - Street 1:390 CHALLENGER RD
Practice Address - Street 2:
Practice Address - City:CAPE CANAVERAL
Practice Address - State:FL
Practice Address - Zip Code:32920-4200
Practice Address - Country:US
Practice Address - Phone:321-633-8640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-02
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003185207Q00000X
FL9111719363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA972007681AMedicaid