Provider Demographics
NPI:1427816784
Name:FANTAW, BROOK T
Entity type:Individual
Prefix:
First Name:BROOK
Middle Name:T
Last Name:FANTAW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3621 WILLISTON RD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-2129
Mailing Address - Country:US
Mailing Address - Phone:952-457-7546
Mailing Address - Fax:
Practice Address - Street 1:3621 WILLISTON RD
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55345-2129
Practice Address - Country:US
Practice Address - Phone:952-457-7546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health