Jennifer Mary Broderick, PA-C

Primary specialty

Surgical Physician AssistantTaxonomy code 363AS0400X

License

9102539 Issued in FL

Practice address

960 7TH Ave N
St Petersburg, FL 33705-1347

Phone

(727) 821-8101

Fax

(727) 894-8360

NPI assigned

Oct 5, 2005

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Miss Jennifer Mary Moon Former name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1128470400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1364515200000",
    "number": "1962499723",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "960 7TH AVE N",
            "city": "ST PETERSBURG",
            "state": "FL",
            "postal_code": "337051347",
            "telephone_number": "727-821-8101",
            "fax_number": "727-894-8360"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "960 7TH AVE N",
            "city": "ST PETERSBURG",
            "state": "FL",
            "postal_code": "337051347",
            "telephone_number": "727-821-8101",
            "fax_number": "727-894-8360"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BRODERICK",
        "first_name": "JENNIFER",
        "middle_name": "MARY",
        "name_prefix": "Mrs.",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2005-10-05",
        "last_updated": "2013-03-29",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363AS0400X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Surgical",
            "state": "FL",
            "license": "9102539",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "291647900",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "JENNIFER",
            "last_name": "MOON",
            "middle_name": "MARY",
            "prefix": "MISS",
            "credential": "PA-C",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

• Jeanine Brock, COTA/L
• John C Brock, MD
• Molly M Brock
• Andrea R Brockman, N.C.C., L.M.H.C.
• David Brockway, PSY.D
• Brodrick ER SVCS Partnership LLC
• Cori E Brodsky, ARNP
• Brian Brolsma
• Diane Rose Bronkema, ROT
• Ashley Bronson

• Surgical Physician Assistant in St Petersburg, FL
• Providers in St Petersburg, FL by specialty
• Surgical Physician Assistant in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 29, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.