Provider Demographics
NPI:1811207335
Name:BROOKS, JUSTIN THOMAS (PA)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:THOMAS
Last Name:BROOKS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 BALDWIN AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-3109
Mailing Address - Country:US
Mailing Address - Phone:704-376-1605
Mailing Address - Fax:704-335-8448
Practice Address - Street 1:225 BALDWIN AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3109
Practice Address - Country:US
Practice Address - Phone:704-376-1605
Practice Address - Fax:704-335-8448
Is Sole Proprietor?:No
Enumeration Date:2010-10-18
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001002584363A00000X
NC0010-02584363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant