Provider Demographics
NPI:1104009737
Name:ETHERINGTON, BROOKE (PA)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:ETHERINGTON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 WILLIAMS WAY
Mailing Address - Street 2:
Mailing Address - City:MOAB
Mailing Address - State:UT
Mailing Address - Zip Code:84532-2370
Mailing Address - Country:US
Mailing Address - Phone:801-633-6268
Mailing Address - Fax:
Practice Address - Street 1:255 WILLIAMS WAY
Practice Address - Street 2:
Practice Address - City:MOAB
Practice Address - State:UT
Practice Address - Zip Code:84532-2370
Practice Address - Country:US
Practice Address - Phone:801-633-6268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-05
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT342203-8906363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical