Provider Demographics
NPI:1821393166
Name:BRODBELT, SHARON LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:LYNN
Last Name:BRODBELT
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:PO BOX 340
Mailing Address - Street 2:
Mailing Address - City:NATURITA
Mailing Address - State:CO
Mailing Address - Zip Code:81422-0340
Mailing Address - Country:US
Mailing Address - Phone:970-865-2665
Mailing Address - Fax:970-865-2674
Practice Address - Street 1:421 ADAMS ST
Practice Address - Street 2:
Practice Address - City:NATURITA
Practice Address - State:CO
Practice Address - Zip Code:81422-5018
Practice Address - Country:US
Practice Address - Phone:970-865-2665
Practice Address - Fax:970-865-2674
Is Sole Proprietor?:No
Enumeration Date:2011-01-18
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA55418363A00000X
NVPA1789363A00000X
AZ8514363A00000X
COPA.0003150363A00000X
CO3150363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO82351562Medicaid