Provider Demographics
NPI:1194369710
Name:COSSABOOM, BROOKE LAUREN
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:LAUREN
Last Name:COSSABOOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2185 RIO RANCHO POINTE PL
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89002-8606
Mailing Address - Country:US
Mailing Address - Phone:951-541-3359
Mailing Address - Fax:
Practice Address - Street 1:2185 RIO RANCHO POINTE PL
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89002-8606
Practice Address - Country:US
Practice Address - Phone:951-541-3359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-06
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant