Provider Demographics
NPI:1982793477
Name:BROBERG, WAYNE (PT)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:
Last Name:BROBERG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6065 MERIDIAN AVE
Mailing Address - Street 2:STE 70
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95120-2772
Mailing Address - Country:US
Mailing Address - Phone:408-927-0871
Mailing Address - Fax:408-927-0891
Practice Address - Street 1:6065 MERIDIAN AVE
Practice Address - Street 2:STE 70
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95120-2772
Practice Address - Country:US
Practice Address - Phone:408-927-0871
Practice Address - Fax:408-927-0891
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT268020Medicare PIN