Provider Demographics
NPI:1154364115
Name:BROOKS, SHANE OP (DO)
Entity type:Individual
Prefix:DR
First Name:SHANE
Middle Name:OP
Last Name:BROOKS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:450 S KITSAP BLVD
Mailing Address - Street 2:#100
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-3773
Mailing Address - Country:US
Mailing Address - Phone:360-744-6275
Mailing Address - Fax:360-895-6296
Practice Address - Street 1:450 S KITSAP BLVD
Practice Address - Street 2:#100
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-3773
Practice Address - Country:US
Practice Address - Phone:360-744-6275
Practice Address - Fax:360-895-6296
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAOP00001839207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2165BROtherBSWA
WA0181442OtherLIWA
WA8326985Medicaid
WA0171367OtherLIWA
WA1594BROtherBSWA
WABSWAOther2264BR
WAH80691Medicare UPIN
WAG8852749Medicare PIN
WAG8853954Medicare PIN
WAP00281046Medicare PIN