Basic Information
| Provider Information | |||||||||
| NPI: | 1053369900 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRACKER | ||||||||
| FirstName: | TROY | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3755 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681030755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023542100 | ||||||||
| FaxNumber: | 4023542155 | ||||||||
| Practice Location | |||||||||
| Address1: | 5908 S 142ND ST | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681372800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023541900 | ||||||||
| FaxNumber: | 4023541910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 07/15/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 19921 | NE | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 47278 | CO | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 47068731741 | 05 | NE | MEDICAID | 47068731706 | 05 | NE | MEDICAID | 47068731734 | 05 | NE | MEDICAID | 10024994800 | 05 | NE | MEDICAID | 1053369900 | 05 | IA | MEDICAID | 47068731749 | 05 | NE | MEDICAID |