Provider Demographics
NPI:1134450497
Name:STIDHAM, BROOKE MARIE (PAC)
Entity type:Individual
Prefix:MRS
First Name:BROOKE
Middle Name:MARIE
Last Name:STIDHAM
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MISS
Other - First Name:BROOKE
Other - Middle Name:MARIE
Other - Last Name:WILLIAMSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PAC
Mailing Address - Street 1:11671 JOLLYVILLE RD
Mailing Address - Street 2:STE 104
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-4141
Mailing Address - Country:US
Mailing Address - Phone:512-345-3599
Mailing Address - Fax:512-345-3599
Practice Address - Street 1:11623 ANGUS RD
Practice Address - Street 2:SUITE 25
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-4003
Practice Address - Country:US
Practice Address - Phone:512-345-9411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-26
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08059363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant