Provider Demographics
NPI:1407842933
Name:ESTABROOK, BRIAN MICHAEL (PA-C)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:MICHAEL
Last Name:ESTABROOK
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 1:5125 SKYWAY
Mailing Address - Street 2:
Mailing Address - City:PARADISE
Mailing Address - State:CA
Mailing Address - Zip Code:95969-5624
Mailing Address - Country:US
Mailing Address - Phone:530-872-2000
Mailing Address - Fax:
Practice Address - Street 1:5125 SKYWAY
Practice Address - Street 2:
Practice Address - City:PARADISE
Practice Address - State:CA
Practice Address - Zip Code:95969-5624
Practice Address - Country:US
Practice Address - Phone:530-872-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16825363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1057708OtherNATIONAL CERTIFICATION
CAPA16825OtherSTATE LICENSE
CAPA16825OtherSTATE LICENSE
CABF583BMedicare PIN