Provider Demographics
NPI:1912529462
Name:NOSOVITSKY, BROOKE A (PA-C)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:A
Last Name:NOSOVITSKY
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 1:2730 COMMERCIAL WAY
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-5693
Mailing Address - Country:US
Mailing Address - Phone:970-964-4036
Mailing Address - Fax:
Practice Address - Street 1:2730 COMMERCIAL WAY
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-5693
Practice Address - Country:US
Practice Address - Phone:970-964-4036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-07
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10774363A00000X
390200000X
TN4311363A00000X
COPA.0008575363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program