=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770216079
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BROOKE ANN PELKE PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2022
-----------------------------------------------------
Last Update Date | 08/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2522 GOLF RD
-----------------------------------------------------
City | EAU CLAIRE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54701-6032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-279-3546
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | W5051 VRADENBERG RD
-----------------------------------------------------
City | DURAND
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54736-4840
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-279-3546
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 841523
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------