Provider Demographics
NPI:1295206381
Name:MYRBERG, BROOKE (PA-C)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:MYRBERG
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 1:9850 GENESEE AVE STE 320
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1208
Mailing Address - Country:US
Mailing Address - Phone:858-554-1212
Mailing Address - Fax:858-554-1222
Practice Address - Street 1:3900 5TH AVE STE 110
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-3122
Practice Address - Country:US
Practice Address - Phone:858-554-1212
Practice Address - Fax:858-554-1222
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA56234363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical