Individual
DIANA KAY BRAZIEL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
3400 SE MACY ROAD, SUITE 18, BENTONVILLE, AR 72712
(479) 268-6800
(479) 268-6802
Mailing address
3400 SE MACY ROAD, SUITE 18, BENTONVILLE, AR 72712
(479) 268-6800
(479) 268-6802
Taxonomy
Speciality
Code
Description
License number
State
208800000X
Urology Physician
Primary
PA-342
AR
363A00000X
Physician Assistant
P-T0807
AR
363A00000X
Physician Assistant
PA-342
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1081767
NCCPA CERTIFICATION NUMBER
—
01
—
P-T0807
TEMPORARY LICENSE STATE OF ARKANSAS
AR
01
—
PA-342
ARKANSAS STATE MEDICAL BOARD LICENSE NUMBER
AR
Enumeration date
06/05/2008
Last updated
06/09/2020
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