Provider Demographics
NPI:1639484181
Name:BROUILLARD, ERIN LYNN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ERIN
Middle Name:LYNN
Last Name:BROUILLARD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9400 BONITA BEACH RD SE
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-4520
Mailing Address - Country:US
Mailing Address - Phone:239-992-5444
Mailing Address - Fax:239-992-1315
Practice Address - Street 1:9400 BONITA BEACH RD SE
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-4520
Practice Address - Country:US
Practice Address - Phone:239-992-5444
Practice Address - Fax:239-992-1315
Is Sole Proprietor?:No
Enumeration Date:2010-08-09
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101960363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP55552Medicare UPIN