Provider Demographics
NPI:1902831985
Name:MARTIN, BROOKE G (PA)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:G
Last Name:MARTIN
Suffix:
Gender:F
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:PO BOX 26028
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6028
Mailing Address - Country:US
Mailing Address - Phone:505-262-7963
Mailing Address - Fax:505-232-1627
Practice Address - Street 1:5150 JOURNAL CENTER BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-5900
Practice Address - Country:US
Practice Address - Phone:505-262-3233
Practice Address - Fax:505-262-3191
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM78-PA005363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM59758Medicaid
NM59758Medicaid