Provider Demographics
NPI:1306061437
Name:BROOKS, STEPHEN DOUGLAS (CRNA)
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:DOUGLAS
Last Name:BROOKS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 DAVID DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MO
Mailing Address - Zip Code:63755-7780
Mailing Address - Country:US
Mailing Address - Phone:573-243-6638
Mailing Address - Fax:573-243-6214
Practice Address - Street 1:1701 LACEY ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-5230
Practice Address - Country:US
Practice Address - Phone:573-334-4822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO068782367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered