Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081P2900X | Pain Medicine | D61663 | MD |
NPI | 1033107941 |
---|---|
Provider Name | Jason P Brokaw |
First Address | Baltimore, MD 21209-3746 |
Second Address | Baltimore, MD 21209-3746 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/10/2005 |
Last Update Date | 06/06/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
405740600 | (05) | MD |
H42416 | (02) |