Provider Demographics
NPI:1881872018
Name:BRACKETT, BENJAMIN EARL (PA-C)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:EARL
Last Name:BRACKETT
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 1:333 1ST ST STE A
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94105-2661
Mailing Address - Country:US
Mailing Address - Phone:415-840-0560
Mailing Address - Fax:
Practice Address - Street 1:333 1ST ST STE A
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94105-2661
Practice Address - Country:US
Practice Address - Phone:415-840-0560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-11
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2018-0030363A00000X
FLPA9112434363A00000X
MAPA7893363A00000X
WAPA61278699363A00000X
TXPA05586363A00000X
IL085.007821363A00000X
PAMA063553363A00000X
CA58410363A00000X
MT36677363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX195992604Medicaid
TX1959926-01Medicaid
TX195992602Medicaid
TX195992603Medicaid
TXPENDINGMedicaid
TX195992603Medicaid
TX195992604Medicaid
TX339132YY17Medicare PIN
TX1959926-01Medicaid
TXTXB127649Medicare PIN