Provider Demographics
NPI:1669135315
Name:RAY, BROOK NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:BROOK
Middle Name:NICOLE
Last Name:RAY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BROOK
Other - Middle Name:NICOLE
Other - Last Name:BLAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4423 NEWTON RD
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-9641
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 E CAMPUS VIEW BLVD STE 250
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43235-4682
Practice Address - Country:US
Practice Address - Phone:614-344-7547
Practice Address - Fax:614-344-7547
Is Sole Proprietor?:No
Enumeration Date:2021-10-20
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.007201RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant