Healthcare Provider Details

I. General information

NPI: 1972985554
Provider Name (Legal Business Name): BROOKE ELIZABETH NYMAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BROOKE ELIZABETH KOCH PA-C

II. Dates (important events)

Enumeration Date: 06/19/2015
Last Update Date: 04/16/2025
Certification Date: 04/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HYGEIA DR
NEWARK DE
19713-2049
US

IV. Provider business mailing address

1800 E PARK AVE
STATE COLLEGE PA
16803-6701
US

V. Phone/Fax

Practice location:
  • Phone: 302-273-1701
  • Fax: 302-273-4497
Mailing address:
  • Phone: 814-234-6110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC5-0012263
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA057682
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: