Provider Demographics
NPI:1710645122
Name:BRODERSEN, HEATH J
Entity type:Individual
Prefix:
First Name:HEATH
Middle Name:J
Last Name:BRODERSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 GREEN MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-1833
Mailing Address - Country:US
Mailing Address - Phone:518-256-7866
Mailing Address - Fax:
Practice Address - Street 1:7 SOUTHWOODS BLVD STE 3
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12211-2526
Practice Address - Country:US
Practice Address - Phone:518-292-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-02
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028114-01363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant