1043414535 NPI number — ALISSA BREKKEN MD

Table of content: ALISSA BREKKEN MD (NPI 1043414535)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043414535 NPI number — ALISSA BREKKEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BREKKEN
Provider First Name:
ALISSA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043414535
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/07/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6210 E HIGHWAY 290 STE 240
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78723-1144
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-483-9596
Provider Business Mailing Address Fax Number:
512-406-6216

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10401 ANDERSON MILL RD STE 110B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78750-2579
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-250-5571
Provider Business Practice Location Address Fax Number:
512-331-0960
Provider Enumeration Date:
06/11/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  4301096703 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: P7398 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 326111701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 326111702 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".