Provider Demographics
NPI:1316938939
Name:BRACKEN, RICHARD (AA-C)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:
Last Name:BRACKEN
Suffix:
Gender:M
Credentials:AA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 PALMYRA RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31701-1528
Mailing Address - Country:US
Mailing Address - Phone:229-434-2161
Mailing Address - Fax:229-434-2502
Practice Address - Street 1:2000 PALMYRA RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-1528
Practice Address - Country:US
Practice Address - Phone:229-434-2161
Practice Address - Fax:229-434-2502
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002558367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA43ZCCCR04Medicare ID - Type Unspecified
GAP87271Medicare UPIN