Provider Demographics
NPI:1528462603
Name:BRAZIEL, JERRY (PA-C)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:BRAZIEL
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 1:714 NINNEKAH ST
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701-5201
Mailing Address - Country:US
Mailing Address - Phone:580-603-1762
Mailing Address - Fax:
Practice Address - Street 1:519 E STATE RD
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:OK
Practice Address - Zip Code:73737-1458
Practice Address - Country:US
Practice Address - Phone:580-227-2585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-17
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2442363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200574140AMedicaid