Healthcare Provider Details

I. General information

NPI: 1043098122
Provider Name (Legal Business Name): CHRISTINA MARIE BROOKS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHRISTINA MARIE CUSICK

II. Dates (important events)

Enumeration Date: 09/19/2023
Last Update Date: 06/10/2025
Certification Date: 06/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 ENTERPRISE DR
AUGUSTA ME
04330-7997
US

IV. Provider business mailing address

15 ENTERPRISE DR
AUGUSTA ME
04330-7997
US

V. Phone/Fax

Practice location:
  • Phone: 207-621-8800
  • Fax: 207-621-8801
Mailing address:
  • Phone: 207-621-8800
  • Fax: 207-621-8801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2727
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: