Basic Information
Provider Information | |||||||||
NPI: | 1366835068 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRACK | ||||||||
FirstName: | JEREMIAH | ||||||||
MiddleName: | C. | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6020 W PARKER RD STE 200 | ||||||||
Address2: |   | ||||||||
City: | PLANO | ||||||||
State: | TX | ||||||||
PostalCode: | 750938172 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9726085000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4370 MEDICAL ARTS DR STE 230 | ||||||||
Address2: |   | ||||||||
City: | FLOWER MOUND | ||||||||
State: | TX | ||||||||
PostalCode: | 750281748 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9729568181 | ||||||||
FaxNumber: | 9729568181 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/05/2015 | ||||||||
LastUpdateDate: | 12/07/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/07/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA12666 | TX | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | PA12666 | 01 | TX | TEXAS MEDICAL BOARD | OTHER |