Provider Demographics
NPI:1881177079
Name:CERKOVNIK, BROOKE ASHLEY (PA-C)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:ASHLEY
Last Name:CERKOVNIK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:ASHLEY
Other - Last Name:MYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1613 STAMPEDE AVE
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-4710
Mailing Address - Country:US
Mailing Address - Phone:307-587-1155
Mailing Address - Fax:307-587-1166
Practice Address - Street 1:1613 STAMPEDE AVE
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-4710
Practice Address - Country:US
Practice Address - Phone:307-587-1155
Practice Address - Fax:307-587-1166
Is Sole Proprietor?:No
Enumeration Date:2018-09-13
Last Update Date:2024-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT69429363A00000X
COPA.0006112363A00000X
WYPA-1204363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant