Provider Demographics
NPI:1144093790
Name:BROOKS, BETHANY
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:BROOKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:872 RIDGE LOOP RD UNIT A
Mailing Address - Street 2:
Mailing Address - City:NORTH POLE
Mailing Address - State:AK
Mailing Address - Zip Code:99705-5346
Mailing Address - Country:US
Mailing Address - Phone:605-290-5792
Mailing Address - Fax:
Practice Address - Street 1:1875 UNIVERSITY AVE S
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-4916
Practice Address - Country:US
Practice Address - Phone:907-328-0875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK215639363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics