Provider Demographics
NPI:1386646032
Name:BROOKS, DAVID ETHAN (PA)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:ETHAN
Last Name:BROOKS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17628 GRANDVIEW DR
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:IL
Mailing Address - Zip Code:61081-8562
Mailing Address - Country:US
Mailing Address - Phone:912-312-1252
Mailing Address - Fax:
Practice Address - Street 1:101 E MILLER RD
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:IL
Practice Address - Zip Code:61081-1252
Practice Address - Country:US
Practice Address - Phone:815-625-4790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL385004697363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical