Basic Information
| Provider Information | |||||||||
| NPI: | 1659674760 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROGDEN | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | JON | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | ACNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 113 PLEASANT VALLEY DR | ||||||||
| Address2: | STE 210 | ||||||||
| City: | BOERNE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780065683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8302674575 | ||||||||
| FaxNumber: | 2105797513 | ||||||||
| Practice Location | |||||||||
| Address1: | 1860 S SEGUIN AVE | ||||||||
| Address2: | |||||||||
| City: | NEW BRAUNFELS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 781303913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104487700 | ||||||||
| FaxNumber: | 2104487703 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2010 | ||||||||
| LastUpdateDate: | 09/20/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 663310 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 208M00000X | 663310 | TX | N | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 12297180 | 01 | TX | CAQH | OTHER |