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General NPI Number Information
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NPI Number | 1447356530
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Entity Type | Individual
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Provider Name | WAYNE LEE BRACKENRICH D.O.
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Gender | Male
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Dates
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Enumeration Date | 09/15/2006
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Last Update Date | 06/26/2024
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Provider Practice Location Address
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Address Line | 6415 PETERS CREEK RD
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City | ROANOKE
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State | VA
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Zip | 24019-4021
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Country | US
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Telephone | 540-265-5500
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Fax | 540-265-5515
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Provider Business Mailing Address
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Address Line | 213 S JEFFERSON ST STE 1006
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City | ROANOKE
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State | VA
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Zip | 24011-1713
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Country | US
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Telephone | 540-224-5705
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Fax | 540-562-4278
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 0102033442
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License Number State | VA
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