Provider Demographics
NPI:1639444383
Name:BROUSSARD, MICHAEL ANTHONY (PA-C)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:BROUSSARD
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:CMR 445 BOX GD ISTC
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09046
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:INTERNATIONAL SPECIAL TRAINING CENTRE
Practice Address - Street 2:STAUFER KASERNE, KASERNENSTR. 20
Practice Address - City:PFULLENDORF
Practice Address - State:BADEN WURTENBERG
Practice Address - Zip Code:88630
Practice Address - Country:DE
Practice Address - Phone:314-537-3976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-14
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NC300534363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VADOOMedicare UPIN