Provider Demographics
NPI:1760455299
Name:BROOMHALL, JO ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:JO ANN
Middle Name:
Last Name:BROOMHALL
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 1:430 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:RUMFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04276-2104
Mailing Address - Country:US
Mailing Address - Phone:207-364-7831
Mailing Address - Fax:
Practice Address - Street 1:430 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:RUMFORD
Practice Address - State:ME
Practice Address - Zip Code:04276-2104
Practice Address - Country:US
Practice Address - Phone:207-364-7831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME032401363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEAP2128Medicare ID - Type Unspecified
MEAP212801Medicare PIN