Provider Demographics
NPI:1790884534
Name:MINGENBACK, BROOKE DIANE (PA)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:DIANE
Last Name:MINGENBACK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:DIANE
Other - Last Name:GATES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 120489
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76012-0489
Mailing Address - Country:US
Mailing Address - Phone:817-375-5200
Mailing Address - Fax:817-299-1731
Practice Address - Street 1:800 ORTHOPEDIC WAY
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76015-1629
Practice Address - Country:US
Practice Address - Phone:817-375-5200
Practice Address - Fax:817-299-1731
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04987363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q75068Medicare UPIN
TX8G9909Medicare PIN