Provider Demographics
NPI:1699965863
Name:MIDDLEBROOK, GINA R (FNP)
Entity type:Individual
Prefix:MRS
First Name:GINA
Middle Name:R
Last Name:MIDDLEBROOK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:R
Other - Last Name:MIDDLEBROOK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:4075 COPPER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-3689
Mailing Address - Country:US
Mailing Address - Phone:804-289-4605
Mailing Address - Fax:
Practice Address - Street 1:4075 COPPER RIDGE DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7059
Practice Address - Country:US
Practice Address - Phone:804-289-4605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024167368207P00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1699965863Medicaid
VAPENDINGMedicare UPIN
VA1699965863Medicaid
VA014447S82Medicare PIN