Healthcare Provider Details

I. General information

NPI: 1720282684
Provider Name (Legal Business Name): THOMAS BROOKSHIRE P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

279 MILLER AVE
MILL VALLEY CA
94941-2832
US

IV. Provider business mailing address

279 MILLER AVE
MILL VALLEY CA
94941-2832
US

V. Phone/Fax

Practice location:
  • Phone: 415-388-2801
  • Fax: 415-388-2803
Mailing address:
  • Phone: 415-388-2801
  • Fax: 415-388-2803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12042
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: