Provider Demographics
NPI:1861471773
Name:BROKKEN, AMY E (PA-C)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:E
Last Name:BROKKEN
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 1:700 ACKERMAN RD
Mailing Address - Street 2:SUITE 570
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-293-2046
Mailing Address - Fax:
Practice Address - Street 1:410 W 10TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1240
Practice Address - Country:US
Practice Address - Phone:614-293-8305
Practice Address - Fax:614-293-3124
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004767363A00000X
FLPA9104538363A00000X
OH50003150363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPENDINGMedicaid
WA7922404Medicaid
FL001600000Medicaid
WA7922404Medicaid
OHPENDINGMedicare PIN