Provider Demographics
NPI:1568114890
Name:HERTENSTEIN, BROOKE (PA-C)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:HERTENSTEIN
Suffix:
Gender:F
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 1:10441 STREAM PARK CT
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45458-9569
Mailing Address - Country:US
Mailing Address - Phone:419-905-5229
Mailing Address - Fax:
Practice Address - Street 1:9000 N MAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45415-1184
Practice Address - Country:US
Practice Address - Phone:419-832-2425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-18
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.007214RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant