Provider Demographics
NPI:1811977184
Name:EDMISTEN, BROOKE OSBORNE (PA-C)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:OSBORNE
Last Name:EDMISTEN
Suffix:
Gender:F
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 1:1126 N CHURCH ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1000
Mailing Address - Country:US
Mailing Address - Phone:336-547-1752
Mailing Address - Fax:336-547-1858
Practice Address - Street 1:1126 N CHURCH ST
Practice Address - Street 2:SUITE 300
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1000
Practice Address - Country:US
Practice Address - Phone:336-547-1752
Practice Address - Fax:336-547-1858
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-00129363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8101245Medicaid
NCQ48042Medicare UPIN
NC8101245Medicaid