Provider Demographics
NPI:1720282684
Name:BROOKSHIRE, THOMAS (PA)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:BROOKSHIRE
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 1:279 MILLER AVE
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-2832
Mailing Address - Country:US
Mailing Address - Phone:415-388-2801
Mailing Address - Fax:415-388-2803
Practice Address - Street 1:279 MILLER AVE
Practice Address - Street 2:
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-2832
Practice Address - Country:US
Practice Address - Phone:415-388-2801
Practice Address - Fax:415-388-2803
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12042363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZS77177Medicare UPIN