Provider Demographics
NPI:1982365193
Name:EVANS, BROOK NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:BROOK
Middle Name:NICOLE
Last Name:EVANS
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 1:400 ROUTE 10 W
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:NJ
Mailing Address - Zip Code:07869-2104
Mailing Address - Country:US
Mailing Address - Phone:973-891-1321
Mailing Address - Fax:
Practice Address - Street 1:161 WASHINGTON VALLEY RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:NJ
Practice Address - Zip Code:07059-7176
Practice Address - Country:US
Practice Address - Phone:630-974-6602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-10
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NJ25MP00694400363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant