Physician Compare National (NPI:1134450497)

HEALTHCARE PROVIDER: BROOKE MARIE STIDHAM PAC

Physician Compare National contains general information about individual eligible professionals (EPs) such as demographic information and Medicare quality program participation.

Individual Professional Information
NPI	1134450497
	Unique healthcare provider (clinician) ID assigned by NPPES
PECOS UID	4284762055
	Unique individual clinician ID assigned by PECOS
Professional Enrollment ID	I20140205000570
	Unique ID for the individual professional enrollment that is the source for the data in the observation
Provider Last Name	STIDHAM
	Individual professional last name
Provider First Name	BROOKE
	Individual professional first name
Provider Middle Name	MARIE
	Individual professional middle name
Provider Gender	F
	The provider's gender if the provider is a person.

Medical School Information
Medical School Name	OTHER
	Individual professional's medical school
Graduation Year	2007
	Individual professional's medical school graduation year
Primary Specialty	PHYSICIAN ASSISTANT
	Primary medical specialty reported by the individual professional in the selected enrollment

Practice Information
Organization Legal Name	LADERA PARK DERMATOLOGY PA
	Legal name of the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
Group Practice PAC ID	5597030189
	Unique Group Practice ID assigned by PECOS to the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
Number of Group Practice members	2
	Total number of individual professionals affiliated with the Group Practice based on Group Practice PAC ID
Line 1 Street Address	11671 JOLLYVILLE RD
	Group Practice or individual's line 1 address
Line 2 Street Address	SUITE 104
	Group Practice or individual's line 2 address
City	AUSTIN
	Group Practice or individual's city
State	TX
	Group Practice or individual's state
Zip Code	787594141
	Group Practice or individual's zip code (9 digits when available)
Phone Number	5123453599
	Phone number is listed only when there is a single phone number available for the practice location address

Hospital(s) Affiliation Information
Professional Accepts Medicare Assignment	Y