Basic Information
| Provider Information | |||||||||
| NPI: | 1154364115 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROOKS | ||||||||
| FirstName: | SHANE | ||||||||
| MiddleName: | OP | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 450 S KITSAP BLVD | ||||||||
| Address2: | #100 | ||||||||
| City: | PORT ORCHARD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983663773 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607446275 | ||||||||
| FaxNumber: | 3608956296 | ||||||||
| Practice Location | |||||||||
| Address1: | 450 S KITSAP BLVD | ||||||||
| Address2: | #100 | ||||||||
| City: | PORT ORCHARD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983663773 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607446275 | ||||||||
| FaxNumber: | 3608956296 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 12/13/2010 | ||||||||
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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 | 207P00000X | OP00001839 | WA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2165BR | 01 | WA | BSWA | OTHER | 0181442 | 01 | WA | LIWA | OTHER | 8326985 | 05 | WA | MEDICAID | 0171367 | 01 | WA | LIWA | OTHER | 1594BR | 01 | WA | BSWA | OTHER | BSWA | 01 | WA | 2264BR | OTHER |