Provider Demographics
NPI:1831170158
Name:BROOKS, KAY MICHELLE (PA C)
Entity type:Individual
Prefix:MRS
First Name:KAY
Middle Name:MICHELLE
Last Name:BROOKS
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1099
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:WA
Mailing Address - Zip Code:98356-0018
Mailing Address - Country:US
Mailing Address - Phone:360-496-5145
Mailing Address - Fax:360-496-5093
Practice Address - Street 1:4254 JACKSON HWY
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-8424
Practice Address - Country:US
Practice Address - Phone:360-262-3966
Practice Address - Fax:360-262-3967
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004588363AM0700X
WAPA0004588207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7132764Medicaid
WA1117829Medicaid
WA7132244Medicaid
WAAB37576Medicare ID - Type Unspecified
WA503898Medicare Oscar/Certification
WA7132244Medicaid
WA1117829Medicaid