Basic Information
| Provider Information | |||||||||
| NPI: | 1851794390 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLS | ||||||||
| FirstName: | BROOKE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RUGGER | ||||||||
| OtherFirstName: | BROOKE | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1518 MULBERRY AVENUE | ||||||||
| Address2: | |||||||||
| City: | MUSCATINE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 52761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5632624112 | ||||||||
| FaxNumber: | 5632648519 | ||||||||
| Practice Location | |||||||||
| Address1: | 1518 MULBERRY AVE | ||||||||
| Address2: | |||||||||
| City: | MUSCATINE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 527613433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5632624112 | ||||||||
| FaxNumber: | 5632648519 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2014 | ||||||||
| LastUpdateDate: | 03/23/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 075627 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.