Provider Demographics
NPI:1366835068
Name:BRACK, JEREMIAH C (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JEREMIAH
Middle Name:C
Last Name:BRACK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6020 W PARKER RD STE 200
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-8172
Mailing Address - Country:US
Mailing Address - Phone:972-608-5000
Mailing Address - Fax:
Practice Address - Street 1:4370 MEDICAL ARTS DR STE 230
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-1748
Practice Address - Country:US
Practice Address - Phone:972-956-8181
Practice Address - Fax:972-956-8181
Is Sole Proprietor?:No
Enumeration Date:2015-03-05
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA12666363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA12666OtherTEXAS MEDICAL BOARD