Provider Demographics
NPI:1215570908
Name:HOMANN, BROOKE LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:LYNN
Last Name:HOMANN
Suffix:
Gender:F
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 1:70 DOCTORS PARK
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-4928
Mailing Address - Country:US
Mailing Address - Phone:573-335-6671
Mailing Address - Fax:573-339-0083
Practice Address - Street 1:70 DOCTORS PARK
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-4928
Practice Address - Country:US
Practice Address - Phone:573-335-6671
Practice Address - Fax:573-339-0083
Is Sole Proprietor?:No
Enumeration Date:2019-10-24
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019037573363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant