=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710788021
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TOM BREAZEAL
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2025
-----------------------------------------------------
Last Update Date | 05/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3601 4TH ST # MS 8182
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79430-0002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-743-9945
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10714 ASHLESHA LN
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77406-2965
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-661-6510
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 367H00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiologist Assistant
-----------------------------------------------------
License Number | 789790577
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------