Basic Information
| Provider Information | |||||||||
| NPI: | 1306159918 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROOKS | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | JOEL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 384 EMBARCADERO W | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946073735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5104659565 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 384 EMBARCADERO W | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946073735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5104659565 | ||||||||
| FaxNumber: | 5104653840 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2010 | ||||||||
| LastUpdateDate: | 06/22/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 04/21/2021 | ||||||||
| NPIReactivationDate: | 05/28/2021 | ||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 06/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 19992 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.