Provider Demographics
NPI:1962499723
Name:BRODERICK, JENNIFER MARY (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MARY
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:MARY
Other - Last Name:MOON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:960 7TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33705-1347
Mailing Address - Country:US
Mailing Address - Phone:727-821-8101
Mailing Address - Fax:727-894-8360
Practice Address - Street 1:960 7TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-1347
Practice Address - Country:US
Practice Address - Phone:727-821-8101
Practice Address - Fax:727-894-8360
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9102539363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291647900Medicaid
FLP98242Medicare UPIN
FLU1343AMedicare PIN