Provider Demographics
NPI:1770557993
Name:PACKARD, BROOKE T (PA)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:T
Last Name:PACKARD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:ANNE
Other - Last Name:TIETSORT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7851 S ELATI ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80120-8080
Mailing Address - Country:US
Mailing Address - Phone:303-759-0854
Mailing Address - Fax:303-759-0864
Practice Address - Street 1:4231 W 16TH AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204-1335
Practice Address - Country:US
Practice Address - Phone:303-629-3721
Practice Address - Fax:303-629-2192
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0002000363A00000X
CO2000207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO51026023Medicaid
COQ33315Medicare UPIN
CO803442Medicare ID - Type Unspecified