MEDICARE: MR. SAMUEL ALLEN BRACKEN CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	656358	TX

General Provider Information

NPI Number	:	1235288341
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SAMUEL ALLEN BRACKEN CRNA

Provider Business Mailing Address
First Line	:	5959 GATEWAY BLVD W STE 120
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79925-3315
Country	:	US
Telephone Number	:	915-779-1716
Fax Number	:	915-771-6496

Provider Business Practice Location Address
First Line	:	1755 CURIE DR
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79902-2919
Country	:	US
Telephone Number	:	915-544-3636
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/09/2007
Last Update Date	:	02/16/2018

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