Provider Demographics
NPI:1235288341
Name:BRACKEN, SAMUEL ALLEN (CRNA)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:ALLEN
Last Name:BRACKEN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5959 GATEWAY BLVD W STE 120
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-3315
Mailing Address - Country:US
Mailing Address - Phone:915-779-1716
Mailing Address - Fax:915-771-6496
Practice Address - Street 1:1755 CURIE DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-2919
Practice Address - Country:US
Practice Address - Phone:915-544-3636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX656358367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered