Provider Demographics
NPI:1609975317
Name:BROADBENT, JUSTIN M (NP)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:M
Last Name:BROADBENT
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:489 HIGGINS ST
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-9564
Mailing Address - Country:US
Mailing Address - Phone:916-985-9670
Mailing Address - Fax:
Practice Address - Street 1:2288 AUBURN BLVD
Practice Address - Street 2:SUITE 106
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95821-1618
Practice Address - Country:US
Practice Address - Phone:916-568-8338
Practice Address - Fax:916-925-3985
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP15480363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN404646Medicaid
CAQ71713Medicare UPIN
CARN404646Medicaid