Provider Demographics
NPI:1528344397
Name:BRAZIEL, JEREMY RYAN (ATC)
Entity type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:RYAN
Last Name:BRAZIEL
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4809 W PLYMOUTH ROCK PL
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72704-6907
Mailing Address - Country:US
Mailing Address - Phone:479-966-4055
Mailing Address - Fax:
Practice Address - Street 1:201 W. VAN ASCHE LOOP
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4974
Practice Address - Country:US
Practice Address - Phone:479-966-4491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-25
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAT3962255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer