Provider Demographics
NPI:1306978580
Name:BRACKETT, DEBORAH SUSAN (MD)
Entity type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:SUSAN
Last Name:BRACKETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 20970
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82003-7020
Mailing Address - Country:US
Mailing Address - Phone:307-996-4777
Mailing Address - Fax:
Practice Address - Street 1:214 E 23RD ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3748
Practice Address - Country:US
Practice Address - Phone:307-432-6629
Practice Address - Fax:307-432-6634
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2021-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY7748A208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1306978580Medicaid