Healthcare Provider Details

I. General information

NPI: 1396731147
Provider Name (Legal Business Name): MARIA T BRASKIE PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 08/18/2025
Certification Date: 08/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 PINE ST
TAMAQUA PA
18252-1409
US

IV. Provider business mailing address

120 PINE ST
TAMAQUA PA
18252-1409
US

V. Phone/Fax

Practice location:
  • Phone: 570-645-1520
  • Fax: 570-645-1519
Mailing address:
  • Phone: 570-645-1520
  • Fax: 570-645-1519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA001308L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: