Healthcare Provider Details

I. General information

NPI: 1780611715
Provider Name (Legal Business Name): PETER MATTHEW BRACKEN P.A.-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23011 BRIARHORN DR
SPRING TX
77389-5244
US

IV. Provider business mailing address

5415 NEWCASTLE AVE #6
ENCINO CA
91316-2012
US

V. Phone/Fax

Practice location:
  • Phone: 818-335-3345
  • Fax:
Mailing address:
  • Phone: 818-335-3345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA14573
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: