Provider Demographics
NPI:1639609696
Name:BRUSTEIN, ALICIA TAYLOR (PA)
Entity Type:Individual
Prefix:MRS
First Name:ALICIA
Middle Name:TAYLOR
Last Name:BRUSTEIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:ALICIA
Other - Middle Name:TAYLOR
Other - Last Name:GARBADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:425 NORTH 21ST STREET
Mailing Address - Street 2:SUITE 405
Mailing Address - City:CAMP HILL
Mailing Address - State:PA
Mailing Address - Zip Code:17011
Mailing Address - Country:US
Mailing Address - Phone:717-695-6553
Mailing Address - Fax:855-383-3233
Practice Address - Street 1:425 NORTH 21ST STREET
Practice Address - Street 2:SUITE 405
Practice Address - City:CAMP HILL
Practice Address - State:PA
Practice Address - Zip Code:17011
Practice Address - Country:US
Practice Address - Phone:717-695-6553
Practice Address - Fax:855-383-3233
Is Sole Proprietor?:No
Enumeration Date:2017-06-13
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA004204363A00000X
PAMA060420363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMA060420OtherNEW LICENSE NUMBER
PA103340644Medicaid