Provider Demographics
NPI:1063436848
Name:BROOKS, JOHNNIE RAY (PA-C)
Entity type:Individual
Prefix:MR
First Name:JOHNNIE
Middle Name:RAY
Last Name:BROOKS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:7305 PURPLE AVENS AVE
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-6327
Mailing Address - Country:US
Mailing Address - Phone:301-599-0787
Mailing Address - Fax:301-599-6808
Practice Address - Street 1:1503 OAK ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-3910
Practice Address - Country:US
Practice Address - Phone:904-634-0640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9103751363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical