Provider Demographics
NPI:1871357426
Name:MESARCH, BRACKEN (APRN)
Entity type:Individual
Prefix:
First Name:BRACKEN
Middle Name:
Last Name:MESARCH
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4815 ALAMEDA AVE
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79905-2705
Mailing Address - Country:US
Mailing Address - Phone:808-927-0719
Mailing Address - Fax:
Practice Address - Street 1:4455 SHADOW WILLOW DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79922-2220
Practice Address - Country:US
Practice Address - Phone:808-927-0719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-13
Last Update Date:2024-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1167694363L00000X
UT9521708-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner