Provider Demographics
NPI:1437294170
Name:HODNICK, BROOKE A (PA)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:A
Last Name:HODNICK
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:PO BOX 35629
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-0629
Mailing Address - Country:US
Mailing Address - Phone:214-424-2200
Mailing Address - Fax:214-231-2159
Practice Address - Street 1:505 S NOLEN DR STE A
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-9167
Practice Address - Country:US
Practice Address - Phone:817-424-1525
Practice Address - Fax:817-424-3491
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03973363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8G2730Medicare ID - Type UnspecifiedPROVIDER NUMBER
TX00N91FMedicare ID - Type UnspecifiedGROUP PROVIDER NUMBER