Provider Demographics
NPI:1215077250
Name:BROOKS, REGAN K (PA-C)
Entity type:Individual
Prefix:
First Name:REGAN
Middle Name:K
Last Name:BROOKS
Suffix:
Gender:M
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 1:4252 HIGHLAND DR.
Mailing Address - Street 2:#200
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84124
Mailing Address - Country:US
Mailing Address - Phone:801-993-1800
Mailing Address - Fax:801-993-1699
Practice Address - Street 1:4252 HIGHLAND DR.
Practice Address - Street 2:#200
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84124
Practice Address - Country:US
Practice Address - Phone:801-993-1800
Practice Address - Fax:801-993-1699
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT57160471206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT0055195503Medicare ID - Type Unspecified
UTQ25514Medicare UPIN