Individual
JERRY BRAZIEL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
P.A.-C
Contact information
Practice address
519 E STATE RD, FAIRVIEW, OK 73737-1458
(580) 227-2585
Mailing address
714 NINNEKAH ST, ENID, OK 73701-5201
(580) 603-1762
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
2442
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200574140A
—
OK
Enumeration date
10/17/2014
Last updated
10/03/2019
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