Basic Information
| Provider Information | |||||||||
| NPI: | 1023353794 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROOKS | ||||||||
| FirstName: | DEVON | ||||||||
| MiddleName: | D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 76 SALMON FALLS RD | ||||||||
| Address2: | |||||||||
| City: | SOMERSWORTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038782815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077355470 | ||||||||
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| Practice Location | |||||||||
| Address1: | 24 HOSPITAL LN | ||||||||
| Address2: | |||||||||
| City: | CALAIS | ||||||||
| State: | ME | ||||||||
| PostalCode: | 046191329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074547521 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2012 | ||||||||
| LastUpdateDate: | 10/05/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 06719323 | NH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 3081124 | 05 | NH | MEDICAID |