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NPI Code Detail

MEDICARE: MR. DAVID ETHAN BROOKS PA

MEDICARE: MR. DAVID ETHAN BROOKS PA
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
1363AS0400XSurgical Physician Assistant385004697IL

General Provider Information

NPI Number : 1386646032
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. DAVID ETHAN BROOKS PA
Provider Business Mailing Address
First Line : 17628 GRANDVIEW DR
Second Line :
City : STERLING
State : IL
Zip : 61081-8562
Country : US
Telephone Number : 912-312-1252
Fax Number :
Provider Business Practice Location Address
First Line : 101 E MILLER RD
Second Line :
City : STERLING
State : IL
Zip : 61081-1252
Country : US
Telephone Number : 815-625-4790
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/12/2005
Last Update Date : 08/21/2024

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