Provider Demographics
NPI:1548607955
Name:PANCIO, BROOKE M (MD)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:M
Last Name:PANCIO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:A
Other - Last Name:MEADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:104 SELMA DR
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-3834
Mailing Address - Country:US
Mailing Address - Phone:540-678-2853
Mailing Address - Fax:540-678-2859
Practice Address - Street 1:2201 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150
Practice Address - Country:US
Practice Address - Phone:530-543-5623
Practice Address - Fax:530-541-5738
Is Sole Proprietor?:No
Enumeration Date:2013-05-24
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA155782207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400161523Medicare PIN