Provider Demographics
NPI:1083933485
Name:BRAZEAL, TIMOTHY CHARLES (MS, ATC, PA)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:CHARLES
Last Name:BRAZEAL
Suffix:
Gender:M
Credentials:MS, ATC, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2851 CLEARVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65704-7212
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:331 HOSPITAL DR
Practice Address - Street 2:SUITE D
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-9217
Practice Address - Country:US
Practice Address - Phone:417-533-6315
Practice Address - Fax:417-533-6320
Is Sole Proprietor?:No
Enumeration Date:2010-05-25
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009018462255A2300X
MO2018004459363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO220051288Medicaid
MO1083933485Medicaid