Provider Demographics
NPI:1972855674
Name:BRODE, ANNA R (PA-C)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:R
Last Name:BRODE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:REGINA
Other - Last Name:DOMDAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 783311
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-3311
Mailing Address - Country:US
Mailing Address - Phone:484-884-4500
Mailing Address - Fax:484-884-0699
Practice Address - Street 1:50 MOISEY DR STE 210
Practice Address - Street 2:
Practice Address - City:HAZLE TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:18202-9297
Practice Address - Country:US
Practice Address - Phone:570-501-6380
Practice Address - Fax:570-501-6389
Is Sole Proprietor?:No
Enumeration Date:2012-10-05
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA055805363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103218100-0001Medicaid
PAMD2760115OtherDEA