Provider Demographics
NPI:1760060586
Name:BROOKS, BETHANY MARIE (PA)
Entity type:Individual
Prefix:MS
First Name:BETHANY
Middle Name:MARIE
Last Name:BROOKS
Suffix:
Gender:
Credentials:PA
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Mailing Address - Street 1:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:314-996-5170
Mailing Address - Fax:314-996-4261
Practice Address - Street 1:3015 N BALLAS RD
Practice Address - Street 2:DEPT RADIOLOGY
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2329
Practice Address - Country:US
Practice Address - Phone:314-996-5170
Practice Address - Fax:314-996-4261
Is Sole Proprietor?:No
Enumeration Date:2021-04-01
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2021017924363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO220097215Medicaid