Healthcare Provider Details

I. General information

NPI: 1386646032
Provider Name (Legal Business Name): DAVID ETHAN BROOKS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E MILLER RD
STERLING IL
61081-1252
US

IV. Provider business mailing address

17628 GRANDVIEW DR
STERLING IL
61081-8562
US

V. Phone/Fax

Practice location:
  • Phone: 815-625-4790
  • Fax:
Mailing address:
  • Phone: 912-312-1252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number385004697
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: