Provider Demographics
NPI:1457451981
Name:BRACKIN, ILENE (PA-C)
Entity Type:Individual
Prefix:
First Name:ILENE
Middle Name:
Last Name:BRACKIN
Suffix:
Gender:F
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 1:310 N 10TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4516
Mailing Address - Country:US
Mailing Address - Phone:701-530-7500
Mailing Address - Fax:701-530-7484
Practice Address - Street 1:310 N 10TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4516
Practice Address - Country:US
Practice Address - Phone:701-530-7500
Practice Address - Fax:701-530-7484
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0236363A00000X, 363AS0400X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDP00210194OtherRAILROAD MEDICARE
ND1457451981OtherNPI