Provider Demographics
NPI:1437187168
Name:BROOKS, NANCY L (PA)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:L
Last Name:BROOKS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 HENDERSON ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2619
Mailing Address - Country:US
Mailing Address - Phone:803-758-2600
Mailing Address - Fax:803-253-8896
Practice Address - Street 1:743 FOLLY RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412-3432
Practice Address - Country:US
Practice Address - Phone:843-762-2360
Practice Address - Fax:843-762-2340
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC750363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P59343Medicare UPIN