Provider Demographics
NPI:1447356530
Name:BRACKENRICH, WAYNE LEE (DO)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:LEE
Last Name:BRACKENRICH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:540-224-5705
Mailing Address - Fax:540-562-4278
Practice Address - Street 1:6415 PETERS CREEK RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24019-4021
Practice Address - Country:US
Practice Address - Phone:540-265-5500
Practice Address - Fax:540-265-5515
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102033442207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1447356530Medicaid
VA005696101Medicaid
016478C93Medicare PIN
VA1447356530Medicaid
VA017668C19Medicare PIN
VAP00477165Medicare PIN
VA010000372Medicare ID - Type Unspecified
VA005696101Medicaid