Provider Demographics
NPI:1356176820
Name:BRONKEN, GARRETT WILLIAM (PA-C)
Entity type:Individual
Prefix:
First Name:GARRETT
Middle Name:WILLIAM
Last Name:BRONKEN
Suffix:
Gender:M
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 1:310 SANTA FE DR STE 112
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-5123
Mailing Address - Country:US
Mailing Address - Phone:760-690-3133
Mailing Address - Fax:
Practice Address - Street 1:310 SANTA FE DR STE 112
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-5123
Practice Address - Country:US
Practice Address - Phone:760-690-3133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-04
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA64900363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant