Provider Demographics
NPI:1598985178
Name:BROOME, LISA A (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:BROOME
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:A
Other - Last Name:KENNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:16 N LA PLATA CT
Mailing Address - Street 2:P.O. BOX 2188
Mailing Address - City:LA PLATA
Mailing Address - State:MD
Mailing Address - Zip Code:20646-4283
Mailing Address - Country:US
Mailing Address - Phone:301-392-3330
Mailing Address - Fax:
Practice Address - Street 1:16 N LA PLATA CT
Practice Address - Street 2:
Practice Address - City:LA PLATA
Practice Address - State:MD
Practice Address - Zip Code:20646-4283
Practice Address - Country:US
Practice Address - Phone:301-392-3330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002687363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDQ07487Medicare UPIN