Provider Demographics
NPI:1780611715
Name:BRACKEN, PETER MATTHEW (PA-C)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:MATTHEW
Last Name:BRACKEN
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 1:5415 NEWCASTLE AVE
Mailing Address - Street 2:#6
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-2012
Mailing Address - Country:US
Mailing Address - Phone:818-335-3345
Mailing Address - Fax:
Practice Address - Street 1:1828 S WESTERN AVE
Practice Address - Street 2:SUITE 10
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-5808
Practice Address - Country:US
Practice Address - Phone:323-730-0310
Practice Address - Fax:323-730-1335
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14573363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA14573OtherMEDICAL LICENSE NUMBER