Provider Demographics
NPI:1174867279
Name:DEWEESE, BROOKE NICOLE (PA)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:NICOLE
Last Name:DEWEESE
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:PO BOX 560825
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80256-0825
Mailing Address - Country:US
Mailing Address - Phone:719-595-7580
Mailing Address - Fax:719-545-0176
Practice Address - Street 1:121 S. CRESCENT DRIVE
Practice Address - Street 2:
Practice Address - City:PUEBLO WEST
Practice Address - State:CO
Practice Address - Zip Code:81007-5433
Practice Address - Country:US
Practice Address - Phone:719-595-7575
Practice Address - Fax:719-288-2799
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0003584363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO89056779Medicaid
CO89056779Medicaid