Provider Demographics
NPI:1477060457
Name:BROOKS, DUSTIN COREY (PA-C)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:COREY
Last Name:BROOKS
Suffix:
Gender:M
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 1:1832 PARKRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-1301
Mailing Address - Country:US
Mailing Address - Phone:405-818-2451
Mailing Address - Fax:
Practice Address - Street 1:6744 NW CACHE RD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-2702
Practice Address - Country:US
Practice Address - Phone:580-536-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-29
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2731363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty