Basic Information
| Provider Information | |||||||||
| NPI: | 1245506799 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHALEN | ||||||||
| FirstName: | BROOKS | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 HEALTH PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048263469 | ||||||||
| FaxNumber: | 9048084608 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 HEALTH PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048263469 | ||||||||
| FaxNumber: | 9048084608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2012 | ||||||||
| LastUpdateDate: | 03/29/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9106470 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.