Provider Demographics
NPI:1649564063
Name:FUENTES, BROOKE WEBSTER (PA-C)
Entity type:Individual
Prefix:MS
First Name:BROOKE
Middle Name:WEBSTER
Last Name:FUENTES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:BROOKE
Other - Middle Name:NICOLE
Other - Last Name:WEBSTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:300 E BLACKSTOCK ROAD
Mailing Address - Street 2:SUITE E
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29301
Mailing Address - Country:US
Mailing Address - Phone:864-285-9861
Mailing Address - Fax:864-595-8281
Practice Address - Street 1:300 E BLACKSTOCK ROAD
Practice Address - Street 2:SUITE E
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301
Practice Address - Country:US
Practice Address - Phone:864-285-9861
Practice Address - Fax:864-595-8281
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-02
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003582363AS0400X
SC1790363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1484PAMedicaid