Provider Demographics
NPI:1114528015
Name:BROOKS, RANDEL (CRNA)
Entity Type:Individual
Prefix:
First Name:RANDEL
Middle Name:
Last Name:BROOKS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1023 SOHO DR
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-4770
Mailing Address - Country:US
Mailing Address - Phone:202-841-6837
Mailing Address - Fax:
Practice Address - Street 1:1023 SOHO DR
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-4770
Practice Address - Country:US
Practice Address - Phone:202-841-6837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-06
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95167168163WC0200X
IAD175480367500000X
CA95001486367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine