Provider Demographics
NPI:1184047904
Name:BRASEL, MICHAEL LUCAS (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LUCAS
Last Name:BRASEL
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 1:4092 HIGHWAY 472
Mailing Address - Street 2:
Mailing Address - City:HAZLEHURST
Mailing Address - State:MS
Mailing Address - Zip Code:39083-9650
Mailing Address - Country:US
Mailing Address - Phone:601-894-4825
Mailing Address - Fax:
Practice Address - Street 1:1777 ELLIS AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-3616
Practice Address - Country:US
Practice Address - Phone:601-371-0400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-30
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00197363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical