Provider Demographics
NPI:1508273301
Name:SMITH, BROOKE (PA-C, ATC, LAT)
Entity Type:Individual
Prefix:MRS
First Name:BROOKE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA-C, ATC, LAT
Other - Prefix:MS
Other - First Name:BROOKE
Other - Middle Name:
Other - Last Name:GRIFFIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC, LAT
Mailing Address - Street 1:20225 BOTHELL EVERETT HWY APT 2013
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98012-8192
Mailing Address - Country:US
Mailing Address - Phone:786-704-3388
Mailing Address - Fax:
Practice Address - Street 1:15805 SW 88TH AVE
Practice Address - Street 2:
Practice Address - City:PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-2022
Practice Address - Country:US
Practice Address - Phone:786-704-3388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-14
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAA1613273132255A2300X
363A00000X
WA61363785363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer