Healthcare Provider Details

I. General information

NPI: 1710788021
Provider Name (Legal Business Name): TOM BREAZEAL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2025
Last Update Date: 05/20/2025
Certification Date: 05/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 4TH ST # MS 8182
LUBBOCK TX
79430-0002
US

IV. Provider business mailing address

10714 ASHLESHA LN
RICHMOND TX
77406-2965
US

V. Phone/Fax

Practice location:
  • Phone: 806-743-9945
  • Fax:
Mailing address:
  • Phone: 208-661-6510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number789790577
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: