Provider Demographics
NPI:1063619336
Name:BIRLING, BROOKE (PA)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:BIRLING
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 ALGOMA ST
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:WI
Mailing Address - Zip Code:54961-2104
Mailing Address - Country:US
Mailing Address - Phone:920-982-8300
Mailing Address - Fax:
Practice Address - Street 1:1420 ALGOMA ST
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:WI
Practice Address - Zip Code:54961-2104
Practice Address - Country:US
Practice Address - Phone:920-982-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2145-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1075095OtherNCCPA