Provider Demographics
NPI:1467072132
Name:BRASKET, ADAM (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:BRASKET
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11704 ETON DR
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-5125
Mailing Address - Country:US
Mailing Address - Phone:618-401-6468
Mailing Address - Fax:
Practice Address - Street 1:5475 E LA PALMA AVE
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92807-2075
Practice Address - Country:US
Practice Address - Phone:949-333-5226
Practice Address - Fax:949-579-9102
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-22
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA743355163W00000X
CA95015268363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse