Provider Demographics
NPI:1659038669
Name:SKINNER, BROOKE LEE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:LEE
Last Name:SKINNER
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4728 REVOLUTION RD
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-1986
Mailing Address - Country:US
Mailing Address - Phone:208-251-8700
Mailing Address - Fax:
Practice Address - Street 1:110 VISTA DR
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5824
Practice Address - Country:US
Practice Address - Phone:208-234-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-24
Last Update Date:2021-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-2154363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant