Provider Demographics
NPI:1417987009
Name:BRACKEEN, PAUL ALLEN (DC)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:ALLEN
Last Name:BRACKEEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 N. ROCK RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037
Mailing Address - Country:US
Mailing Address - Phone:316-789-8100
Mailing Address - Fax:316-789-9400
Practice Address - Street 1:320 N. ROCK RD
Practice Address - Street 2:SUITE 300
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037
Practice Address - Country:US
Practice Address - Phone:316-789-8100
Practice Address - Fax:316-789-9400
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04628111N00000X
KSLIC-4-08-2400111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS060929Medicare UPIN