MEDICARE: BROOKE ETHINGTON PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	6303	AZ

General Provider Information

NPI Number	:	1366808610
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BROOKE ETHINGTON PA-C

Provider Business Mailing Address
First Line	:	1250 S CLEARVIEW AVE
Second Line	:	SUITE 100
City	:	MESA
State	:	AZ
Zip	:	85209-3378
Country	:	US
Telephone Number	:	480-423-4670
Fax Number	:

Provider Business Practice Location Address
First Line	:	1635 N GREENFIELD RD
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85205-4005
Country	:	US
Telephone Number	:	480-840-3075
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/31/2015
Last Update Date	:	02/20/2016

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Directions to “ BROOKE ETHINGTON PA-C” Practice Location

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