Healthcare Provider Details

I. General information

NPI: 1619066024
Provider Name (Legal Business Name): BRUCE A BRASWELL PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 09/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 N MAIN ST
SIKESTON MO
63801-5044
US

IV. Provider business mailing address

PO BOX 65
VANDALIA IL
62471-0065
US

V. Phone/Fax

Practice location:
  • Phone: 573-472-6001
  • Fax: 573-472-6006
Mailing address:
  • Phone: 618-367-1921
  • Fax: 618-283-4081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number117542
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number117542
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: