=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386646032
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID ETHAN BROOKS PA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2005
-----------------------------------------------------
Last Update Date | 08/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 E MILLER RD
-----------------------------------------------------
City | STERLING
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61081-1252
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-625-4790
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17628 GRANDVIEW DR
-----------------------------------------------------
City | STERLING
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61081-8562
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-312-1252
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | 385004697
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------