Provider Demographics
NPI:1700835642
Name:BROOKS, JOHANNA M (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:M
Last Name:BROOKS
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 1:14239 WEST BELL ROAD
Mailing Address - Street 2:SUITE 112
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-2469
Mailing Address - Country:US
Mailing Address - Phone:623-876-9983
Mailing Address - Fax:623-876-9984
Practice Address - Street 1:14239 WEST BELL ROAD
Practice Address - Street 2:SUITE 112
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-2469
Practice Address - Country:US
Practice Address - Phone:623-876-9983
Practice Address - Fax:623-876-9984
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3785363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ3785OtherARIZONA REGULATORY BOARD OF PHYSICIAN ASSISTANTS