Provider Demographics
NPI:1235486036
Name:BRACK, ELYSE LYNN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ELYSE
Middle Name:LYNN
Last Name:BRACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:ELYSE
Other - Middle Name:LYNN
Other - Last Name:DOBRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3560 DELAWARE ST
Mailing Address - Street 2:SUITE 901
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-3067
Mailing Address - Country:US
Mailing Address - Phone:409-898-3900
Mailing Address - Fax:409-898-3901
Practice Address - Street 1:3560 DELAWARE ST
Practice Address - Street 2:SUITE 901
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-3067
Practice Address - Country:US
Practice Address - Phone:409-898-3900
Practice Address - Fax:409-898-3901
Is Sole Proprietor?:No
Enumeration Date:2012-08-10
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA07970363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant