Healthcare Provider Details

I. General information

NPI: 1881872018
Provider Name (Legal Business Name): BENJAMIN EARL BRACKETT P.A.-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2008
Last Update Date: 10/28/2022
Certification Date: 10/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 1ST ST STE A
SAN FRANCISCO CA
94105-2661
US

IV. Provider business mailing address

333 1ST ST STE A
SAN FRANCISCO CA
94105-2661
US

V. Phone/Fax

Practice location:
  • Phone: 415-840-0560
  • Fax:
Mailing address:
  • Phone: 415-840-0560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2018-0030
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9112434
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA7893
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA61278699
License Number StateWA
# 5
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA05586
License Number StateTX
# 6
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.007821
License Number StateIL
# 7
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA063553
License Number StatePA
# 8
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number58410
License Number StateCA
# 9
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number36677
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: