Provider Demographics
NPI:1649670159
Name:BRODEUR, THERESA MICHELLE (PA-C)
Entity type:Individual
Prefix:MS
First Name:THERESA
Middle Name:MICHELLE
Last Name:BRODEUR
Suffix:
Gender:F
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 1:2731 SEDALIA CIR
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-4627
Mailing Address - Country:US
Mailing Address - Phone:315-447-3130
Mailing Address - Fax:
Practice Address - Street 1:1600 S 48TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-1283
Practice Address - Country:US
Practice Address - Phone:402-481-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-03
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant