Healthcare Provider Details

I. General information

NPI: 1558026377
Provider Name (Legal Business Name): DAKOTA BENJAMIN BROOKER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2021
Last Update Date: 10/09/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 WHEELING AVE
GLEN DALE WV
26038-1697
US

IV. Provider business mailing address

800 WHEELING AVE
GLEN DALE WV
26038-1697
US

V. Phone/Fax

Practice location:
  • Phone: 304-221-4570
  • Fax:
Mailing address:
  • Phone: 304-845-3211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.007121RX
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2562
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: