Provider Demographics
NPI:1558048645
Name:BRACKEN, QUAVON L
Entity Type:Individual
Prefix:
First Name:QUAVON
Middle Name:L
Last Name:BRACKEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 W 26TH AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-2532
Mailing Address - Country:US
Mailing Address - Phone:907-929-2633
Mailing Address - Fax:
Practice Address - Street 1:704 W 26TH AVE STE 206
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-2532
Practice Address - Country:US
Practice Address - Phone:907-929-2633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-29
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist