Provider Demographics
NPI:1245633056
Name:BRACKEN, SCOTT (CSA)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:BRACKEN
Suffix:
Gender:M
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 MICHAELWOOD DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-4612
Mailing Address - Country:US
Mailing Address - Phone:757-348-7101
Mailing Address - Fax:757-855-1192
Practice Address - Street 1:1008 MICHAELWOOD DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-4612
Practice Address - Country:US
Practice Address - Phone:757-348-7101
Practice Address - Fax:757-855-1192
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-07
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA4404246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant