Healthcare Provider Details

I. General information

NPI: 1780611715
Provider Name (Legal Business Name): PETER MATTHEW BRACKEN P.A.-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 02/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1828 S WESTERN AVE SUITE 10
LOS ANGELES CA
90006-5808
US

IV. Provider business mailing address

5415 NEWCASTLE AVE #6
ENCINO CA
91316-2012
US

V. Phone/Fax

Practice location:
  • Phone: 323-730-0310
  • Fax: 323-730-1335
Mailing address:
  • Phone: 818-335-3345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA14573
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: