Provider Demographics
NPI:1003876087
Name:BROOKS, ROBERTA J (PA-C)
Entity Type:Individual
Prefix:MS
First Name:ROBERTA
Middle Name:J
Last Name:BROOKS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3055 SANFORD CIR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-4925
Mailing Address - Country:US
Mailing Address - Phone:970-624-4420
Mailing Address - Fax:970-624-4459
Practice Address - Street 1:2127 E HARMONY RD
Practice Address - Street 2:SUITE 140
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-3405
Practice Address - Country:US
Practice Address - Phone:970-297-6250
Practice Address - Fax:970-297-6260
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1500312363AM0700X
CO2595363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100377320DMedicaid
KS100377320DMedicaid
P01654Medicare UPIN