Provider Demographics
NPI:1477821130
Name:CORDOVA, BROOKE VANESSA (PA-C)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:VANESSA
Last Name:CORDOVA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:VANESSA
Other - Last Name:PERDOMO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 73720
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99707-3720
Mailing Address - Country:US
Mailing Address - Phone:814-594-1319
Mailing Address - Fax:
Practice Address - Street 1:1001 NOBLE ST STE 1
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4991
Practice Address - Country:US
Practice Address - Phone:907-459-3520
Practice Address - Fax:907-459-3541
Is Sole Proprietor?:No
Enumeration Date:2011-12-09
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106366363A00000X
AK164786363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant