Basic Information
| Provider Information | |||||||||
| NPI: | 1053528364 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROOKS | ||||||||
| FirstName: | JULIE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 BUTTRICK RD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | LONDONDERRY | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030533417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035371300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 14 TSIENNETO RD STE 200A | ||||||||
| Address2: | |||||||||
| City: | DERRY | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035371300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2007 | ||||||||
| LastUpdateDate: | 08/08/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0487 P | NH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 30332545 | 05 | NH | MEDICAID |