Provider Demographics
NPI:1013003557
Name:BROOKS, MITCHELL BRIAN (PA)
Entity Type:Individual
Prefix:MR
First Name:MITCHELL
Middle Name:BRIAN
Last Name:BROOKS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 KATHERINE LOOP
Mailing Address - Street 2:
Mailing Address - City:LEESVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71446
Mailing Address - Country:US
Mailing Address - Phone:573-452-3055
Mailing Address - Fax:
Practice Address - Street 1:1585 3RD STREET
Practice Address - Street 2:
Practice Address - City:FT POLK
Practice Address - State:LA
Practice Address - Zip Code:71459
Practice Address - Country:US
Practice Address - Phone:337-531-3919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical