Provider Demographics
NPI:1225297260
Name:BRAZIEL, DIANA KAY (PA-C)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:KAY
Last Name:BRAZIEL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:KAY
Other - Last Name:VINSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3400 SE MACY ROAD
Mailing Address - Street 2:SUITE 18
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712
Mailing Address - Country:US
Mailing Address - Phone:479-268-6800
Mailing Address - Fax:479-268-6802
Practice Address - Street 1:3400 SE MACY ROAD
Practice Address - Street 2:SUITE 18
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712
Practice Address - Country:US
Practice Address - Phone:479-268-6800
Practice Address - Fax:479-268-6802
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP-T0807363A00000X
ARPA-342363A00000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARPA-342OtherARKANSAS STATE MEDICAL BOARD LICENSE NUMBER
ARP-T0807OtherTEMPORARY LICENSE STATE OF ARKANSAS
1081767OtherNCCPA CERTIFICATION NUMBER