Provider Demographics
NPI:1437437845
Name:SIMONES, BROOKE BUCKENTINE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:BROOKE
Middle Name:BUCKENTINE
Last Name:SIMONES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:BROOKE
Other - Middle Name:CHANDRA
Other - Last Name:BUCKENTINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:516 DELAWARE ST SE
Mailing Address - Street 2:PHILLIPS-WANGENSTEEN BUILDING 2-200
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-0356
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2420 HERON LN
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:MN
Practice Address - Zip Code:55386-4558
Practice Address - Country:US
Practice Address - Phone:952-994-9440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-02
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11322363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO152360526Medicare PIN