Healthcare Provider Details

I. General information

NPI: 1962401554
Provider Name (Legal Business Name): BRIAN SCOTT BROOKS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 02/25/2020
Certification Date: 02/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22066 SE 71ST AVE
HAWTHORNE FL
32640-3969
US

IV. Provider business mailing address

1302 RIVER ST
PALATKA FL
32177-5042
US

V. Phone/Fax

Practice location:
  • Phone: 352-481-2700
  • Fax: 352-481-2392
Mailing address:
  • Phone: 386-326-7342
  • Fax: 386-325-1086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA3061
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: