Provider Demographics
NPI:1407245731
Name:STEPHENS, BROOKE MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:MARIE
Last Name:STEPHENS
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:PO BOX 1520
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70073
Mailing Address - Country:US
Mailing Address - Phone:504-349-6423
Mailing Address - Fax:504-934-8097
Practice Address - Street 1:1111 MEDICAL CENTER BLVD.
Practice Address - Street 2:SUITE S-450
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3151
Practice Address - Country:US
Practice Address - Phone:504-349-6401
Practice Address - Fax:504-349-6444
Is Sole Proprietor?:No
Enumeration Date:2015-01-09
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.200783363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2381130Medicaid
LA387754Medicare PIN