Provider Demographics
NPI:1780967364
Name:BROADUS, TRENT MICHAEL (ARNP)
Entity type:Individual
Prefix:
First Name:TRENT
Middle Name:MICHAEL
Last Name:BROADUS
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1695 NORTH SUNRISE WAY
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-3701
Mailing Address - Country:US
Mailing Address - Phone:760-323-2118
Mailing Address - Fax:760-416-1651
Practice Address - Street 1:1695 N SUNRISE WAY
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-3701
Practice Address - Country:US
Practice Address - Phone:760-323-2118
Practice Address - Fax:760-416-1651
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-21
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9353539363L00000X
TX570228363LA2100X
CA95006008363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95006008OtherCA NP LICENSE
FLARNP9353539OtherFLA MEDICAL LICENSE
FLARNP9353539OtherFLA MEDICAL LICENSE