Provider Demographics
NPI:1619381092
Name:BROOKS, JOSEPH
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:BROOKS
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:PO BOX 125
Mailing Address - Street 2:
Mailing Address - City:MOUNT WASHINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40047-0125
Mailing Address - Country:US
Mailing Address - Phone:502-357-9211
Mailing Address - Fax:502-576-7400
Practice Address - Street 1:2233 LOWER HUNTERS TRCE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-1358
Practice Address - Country:US
Practice Address - Phone:502-357-9211
Practice Address - Fax:502-576-7400
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-13
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11010350363LF0000X
KY3008699363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100305570Medicaid
12704008OtherCAQH