Provider Demographics
NPI:1609822402
Name:STOKER, BREK DAVID (AUD, CCC-A)
Entity Type:Individual
Prefix:
First Name:BREK
Middle Name:DAVID
Last Name:STOKER
Suffix:
Gender:M
Credentials:AUD, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13176 W PERSIMMON LN
Mailing Address - Street 2:#120
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-1986
Mailing Address - Country:US
Mailing Address - Phone:208-376-3591
Mailing Address - Fax:208-376-3594
Practice Address - Street 1:13176 W PERSIMMON LN
Practice Address - Street 2:#120
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-1986
Practice Address - Country:US
Practice Address - Phone:208-376-3591
Practice Address - Fax:208-376-3594
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDH-412174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010143649OtherBLUE SHIELD OF ID
ID805959200Medicaid
IDAU571OtherBLUE CROSS OF ID