Provider Demographics
NPI:1669592960
Name:BROOKS, TANYA (PA-C)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:BROOKS
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 1:524 N ANDOVER RD
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:KS
Mailing Address - Zip Code:67002-9712
Mailing Address - Country:US
Mailing Address - Phone:316-733-0716
Mailing Address - Fax:316-733-1240
Practice Address - Street 1:9350 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-2555
Practice Address - Country:US
Practice Address - Phone:316-686-6608
Practice Address - Fax:316-686-3426
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1500710363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS426930OtherBCBS
KS426930OtherBCBS