Provider Demographics
NPI:1811465420
Name:SOUTHERLAND, BROOKE MCKENZIE (PA-C, MPAS)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:MCKENZIE
Last Name:SOUTHERLAND
Suffix:
Gender:F
Credentials:PA-C, MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1990 LAYTON RD
Mailing Address - Street 2:
Mailing Address - City:FOWLERVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48836-8984
Mailing Address - Country:US
Mailing Address - Phone:517-672-9113
Mailing Address - Fax:
Practice Address - Street 1:18901 LAKE SHORE BLVD
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44119-1078
Practice Address - Country:US
Practice Address - Phone:216-531-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-13
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.006624363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical