Provider Demographics
NPI:1093763377
Name:BROOKS, NATHAN M (MD)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:M
Last Name:BROOKS
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:12075 E STATE ROUTE 69
Mailing Address - Street 2:
Mailing Address - City:DEWEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86327-4517
Mailing Address - Country:US
Mailing Address - Phone:928-772-1673
Mailing Address - Fax:928-772-1674
Practice Address - Street 1:2352 QUARTER HORSE TRL
Practice Address - Street 2:
Practice Address - City:OVERGAARD
Practice Address - State:AZ
Practice Address - Zip Code:85933-5319
Practice Address - Country:US
Practice Address - Phone:928-535-3616
Practice Address - Fax:928-532-2156
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2023-11-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ34307207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ976847Medicaid
106947Medicare ID - Type Unspecified
AZ976847Medicaid