Basic Information
| Provider Information | |||||||||
| NPI: | 1174879282 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRODERICK | ||||||||
| FirstName: | KIERON | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | RN, ACNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3901 SPICEWOOD SPRINGS RD STE 201 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787598723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8772795960 | ||||||||
| FaxNumber: | 8773843106 | ||||||||
| Practice Location | |||||||||
| Address1: | 1208 E CROSS ST | ||||||||
| Address2: | |||||||||
| City: | CENTERVILLE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 525443501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164777200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2012 | ||||||||
| LastUpdateDate: | 02/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 2012024476 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363L00000X | L166512 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.