Provider Demographics
NPI:1598220881
Name:BROZ, JOHN JOSEPH III (PA)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:JOSEPH
Last Name:BROZ
Suffix:III
Gender:M
Credentials:PA
Other - Prefix:MR
Other - First Name:JOHN
Other - Middle Name:JOSEPH
Other - Last Name:BROZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:4127 VIA MARINA APT 312
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-5352
Mailing Address - Country:US
Mailing Address - Phone:561-271-8963
Mailing Address - Fax:
Practice Address - Street 1:15107 VANOWEN ST
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-4542
Practice Address - Country:US
Practice Address - Phone:561-271-8963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-31
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363AM0700X
390200000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program