Healthcare Provider Details

I. General information

NPI: 1013003557
Provider Name (Legal Business Name): MITCHELL BRIAN BROOKS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1585 3RD STREET
FT POLK LA
71459
US

IV. Provider business mailing address

9 KATHERINE LOOP
LEESVILLE LA
71446
US

V. Phone/Fax

Practice location:
  • Phone: 337-531-3919
  • Fax:
Mailing address:
  • Phone: 573-452-3055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: