Provider Demographics
NPI:1689449522
Name:CORCORAN, BROOKE LAEL (PA)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:LAEL
Last Name:CORCORAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:LAEL
Other - Last Name:TOMPKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4016 KIRKSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:KY
Mailing Address - Zip Code:40444-8659
Mailing Address - Country:US
Mailing Address - Phone:859-358-5612
Mailing Address - Fax:
Practice Address - Street 1:2360 DUCK CREEK PKWY
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-3300
Practice Address - Country:US
Practice Address - Phone:920-965-0345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-21
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7704363A00000X
MI5601012169363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant