Provider Demographics
NPI:1194316182
Name:HERNANDEZ, BROOKE (PA-C)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:571 NW 205TH AVE
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-3476
Mailing Address - Country:US
Mailing Address - Phone:954-330-2451
Mailing Address - Fax:
Practice Address - Street 1:1120 BAYVIEW DR
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-2505
Practice Address - Country:US
Practice Address - Phone:954-537-4106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-01
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9113972363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant