Provider Demographics
NPI:1730987637
Name:ELCONIN, BROOKE (PA-C)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:ELCONIN
Suffix:
Gender:X
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 1:1826 EDDY ST UNIT 102
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115-3947
Mailing Address - Country:US
Mailing Address - Phone:818-522-5079
Mailing Address - Fax:
Practice Address - Street 1:350 30TH ST STE 100
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3422
Practice Address - Country:US
Practice Address - Phone:510-204-1844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-05
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA66102363A00000X
CA66102207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty