Provider Demographics
NPI:1770180960
Name:BROUCEK, ELYSE RENEE
Entity type:Individual
Prefix:
First Name:ELYSE
Middle Name:RENEE
Last Name:BROUCEK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4045 E BELL RD STE 125
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-2238
Mailing Address - Country:US
Mailing Address - Phone:602-971-0268
Mailing Address - Fax:602-971-1556
Practice Address - Street 1:4045 E BELL RD STE 125
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-2238
Practice Address - Country:US
Practice Address - Phone:602-971-0268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-01
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program