Healthcare Provider Details

I. General information

NPI: 1467072132
Provider Name (Legal Business Name): ADAM BRASKET NURSE PRACTITIONER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2020
Last Update Date: 09/24/2020
Certification Date: 09/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5475 E LA PALMA AVE
ANAHEIM CA
92807-2075
US

IV. Provider business mailing address

11704 ETON DR
GRAND TERRACE CA
92313-5125
US

V. Phone/Fax

Practice location:
  • Phone: 949-333-5226
  • Fax: 949-579-9102
Mailing address:
  • Phone: 618-401-6468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number743355
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95015268
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: