Healthcare Provider Details

I. General information

NPI: 1184047904
Provider Name (Legal Business Name): MICHAEL LUCAS BRASEL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2014
Last Update Date: 01/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1777 ELLIS AVE
JACKSON MS
39204-3616
US

IV. Provider business mailing address

4092 HIGHWAY 472
HAZLEHURST MS
39083-9650
US

V. Phone/Fax

Practice location:
  • Phone: 601-371-0400
  • Fax:
Mailing address:
  • Phone: 601-894-4825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA00197
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: