Provider Demographics
NPI:1558753327
Name:BRACKETT, CALEB
Entity type:Individual
Prefix:
First Name:CALEB
Middle Name:
Last Name:BRACKETT
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 E 20TH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-3882
Mailing Address - Country:US
Mailing Address - Phone:307-633-7444
Mailing Address - Fax:
Practice Address - Street 1:800 E 20TH ST STE 300
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3882
Practice Address - Country:US
Practice Address - Phone:307-633-7444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-03
Last Update Date:2025-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X, 390200000X
WY18332A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No172V00000XOther Service ProvidersCommunity Health Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program