Provider Demographics
NPI:1235109562
Name:LUENENBORG, BROOKE K (PAC)
Entity Type:Individual
Prefix:MRS
First Name:BROOKE
Middle Name:K
Last Name:LUENENBORG
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 E C ST
Mailing Address - Street 2:
Mailing Address - City:NORTH PLATTE
Mailing Address - State:NE
Mailing Address - Zip Code:69101-5411
Mailing Address - Country:US
Mailing Address - Phone:308-532-6165
Mailing Address - Fax:308-532-7464
Practice Address - Street 1:106 E C ST
Practice Address - Street 2:
Practice Address - City:NORTH PLATTE
Practice Address - State:NE
Practice Address - Zip Code:69101-5411
Practice Address - Country:US
Practice Address - Phone:308-532-6165
Practice Address - Fax:308-532-7464
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1090363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEQ14880Medicare UPIN
NE277207Medicare ID - Type Unspecified