Provider Demographics
NPI:1184889768
Name:BROKENICKY, ALAN LEE (PA)
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:LEE
Last Name:BROKENICKY
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 1:1705 E 19TH ST
Mailing Address - Street 2:STE 302
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5410
Mailing Address - Country:US
Mailing Address - Phone:918-748-7585
Mailing Address - Fax:
Practice Address - Street 1:9912 E 21ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74129-1620
Practice Address - Country:US
Practice Address - Phone:918-622-0641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1752363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant