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General NPI Number Information
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NPI Number | 1083933485
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Entity Type | Individual
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Provider Name | TIMOTHY CHARLES BRAZEAL MS, ATC, PA
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Gender | Male
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Dates
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Enumeration Date | 05/25/2010
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Last Update Date | 07/23/2024
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Provider Practice Location Address
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Address Line | 331 HOSPITAL DR SUITE D
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City | LEBANON
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State | MO
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Zip | 65536-9217
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Country | US
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Telephone | 417-533-6315
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Fax | 417-533-6320
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Provider Business Mailing Address
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Address Line | 2851 CLEARVIEW DR
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City | MANSFIELD
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State | MO
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Zip | 65704-7212
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 200901846
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 2018004459
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License Number State | MO
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