Provider Demographics
NPI:1063718393
Name:BEEBE, BROOKE BALLASES (PA)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:BALLASES
Last Name:BEEBE
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 1:12200 RENFERT WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-5614
Mailing Address - Country:US
Mailing Address - Phone:512-451-8211
Mailing Address - Fax:
Practice Address - Street 1:12200 RENFERT WAY
Practice Address - Street 2:STE 100
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-5614
Practice Address - Country:US
Practice Address - Phone:512-451-8211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-03
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06726363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX70174346OtherDPS
TXPA06726OtherPA LICENSE NUMBER