Basic Information
| Provider Information | |||||||||
| NPI: | 1588755482 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROOKS | ||||||||
| FirstName: | HAIDY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 WHITCHER STREET | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704246893 | ||||||||
| FaxNumber: | 7704249095 | ||||||||
| Practice Location | |||||||||
| Address1: | 5885 GLENRIDGE DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303285572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1888908055 | ||||||||
| FaxNumber: | 7205980440 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 08/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 004751 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 781124758F | 05 | GA | MEDICAID | 781124758D | 05 | GA | MEDICAID | 781124758C | 05 | GA | MEDICAID | 781124758B | 05 | GA | MEDICAID | 781124758E | 05 | GA | MEDICAID |