Healthcare Provider Details

I. General information

NPI: 1760272298
Provider Name (Legal Business Name): BROOKE MCKEOWN
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2025
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 NOVELL PL
PROVO UT
84606-6171
US

IV. Provider business mailing address

1800 NOVELL PL
PROVO UT
84606-6171
US

V. Phone/Fax

Practice location:
  • Phone: 309-798-9848
  • Fax:
Mailing address:
  • Phone: 309-798-9848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number915523
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: