Provider Demographics
NPI:1134382013
Name:BROAD, JOSHUA A (PA)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:A
Last Name:BROAD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12380 HESPERIA RD
Mailing Address - Street 2:#2
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-5814
Mailing Address - Country:US
Mailing Address - Phone:760-243-4188
Mailing Address - Fax:714-243-6888
Practice Address - Street 1:1314 N NORMA ST
Practice Address - Street 2:
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555-2509
Practice Address - Country:US
Practice Address - Phone:760-446-2935
Practice Address - Fax:760-446-2937
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-09
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19744363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA19744OtherSTATE LICENSE
CA1082405OtherBOARD CERTIFICATION
CAPA19744OtherSTATE LICENSE
CA1082405OtherBOARD CERTIFICATION
CAW2069901Medicare PIN