Provider Demographics
NPI:1134931496
Name:BAIN, BROOKE ALEXANDRA (PA-C)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:ALEXANDRA
Last Name:BAIN
Suffix:
Gender:
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 1:17800 NEWBURGH RD STE 103
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-2794
Mailing Address - Country:US
Mailing Address - Phone:734-464-9540
Mailing Address - Fax:734-464-0438
Practice Address - Street 1:17800 NEWBURGH RD STE 103
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-2794
Practice Address - Country:US
Practice Address - Phone:734-464-9540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-23
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant