Provider Demographics
NPI:1134466485
Name:BROOKS, COREY A (PA-C)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:A
Last Name:BROOKS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 S 3RD ST STE 104
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-1952
Mailing Address - Country:US
Mailing Address - Phone:618-222-4701
Mailing Address - Fax:618-222-4754
Practice Address - Street 1:180 S 3RD ST STE 104
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1952
Practice Address - Country:US
Practice Address - Phone:618-222-4701
Practice Address - Fax:618-222-4754
Is Sole Proprietor?:No
Enumeration Date:2013-01-07
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004575363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant