NPIMap

Individual provider Active NPI

Timothy Charles Brazeal, MS, ATC, PA

  • Physician Assistant
  • Lebanon, MO
National Provider Identifier
1083933485
Registry record updated Jul 23, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
2018004459 Issued in MO
Practice address
331 Hospital Dr
Suite D
Lebanon, MO 65536-9217
Phone
(417) 533-6315
Fax
(417) 533-6320
NPI assigned
May 25, 2010
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jul 23, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Athletic Trainer 2255A2300X 200901846 MO
Physician Assistant 363A00000X 2018004459 MO Primary

Addresses

Primary practice location

331 Hospital Dr
Suite D
Lebanon, MO 65536-9217

Mailing address

2851 Clearview Dr
Mansfield, MO 65704-7212

Other identifiers 2

IdentifierTypeStateIssuer
220051288MedicaidMO
1083933485MedicaidMO

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MO
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20180212001368 MO Practitioner - Physician Assistant 0547520561 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2017
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Mercy Clinic Springfield CommunitiesGroup PAC ID 7416865845, 1,121 clinicians

Practice addresses (Care Compare)

1235 E Cherokee St
Springfield, MO 65804-2203

1605 Martin Springs Dr
Rolla, MO 65401-2980

2115 S Fremont Ave
3050 MC Infectious Disease Whiteside
Springfield, MO 65804-2236
Phone (417) 820-3905

3050 E River Bluff Blvd
MC Orthopedics
Ozark, MO 65721-8807
Phone (417) 820-5610

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Master of Science, Physician Assistant

State licenses

LicenseStateTypeSpecialty
200901846MOMDAthletic Trainer

Practice roles

OrganizationSpecialtyStatusNew patients
Mercy Clinic Springfield Communities CurrentSince Jun 24, 2024 Accepting new patients
Mercy Clinic Springfield Communities CurrentSince Jun 24, 2024 Accepting new patients
Ozarks Medical Center Past Accepting new patients

Locations

331 Hospital Dr
Ste D
Lebanon, MO 65536
Phone (417) 533-6100

1605 Martin Springs Dr
Rolla, MO 65401
Phone (573) 458-6379

1235 E Cherokee St
Springfield, MO 65804
Phone (417) 820-2115

2115 S Fremont Ave
Ste 3050
Springfield, MO 65804
Phone (417) 820-3905

Organizations & group practices 4

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 11

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1274745600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1721692800000",
    "number": "1083933485",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2851 CLEARVIEW DR",
            "city": "MANSFIELD",
            "state": "MO",
            "postal_code": "657047212"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "331 HOSPITAL DR",
            "address_2": "SUITE D",
            "city": "LEBANON",
            "state": "MO",
            "postal_code": "655369217",
            "telephone_number": "417-533-6315",
            "fax_number": "417-533-6320"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BRAZEAL",
        "first_name": "TIMOTHY",
        "middle_name": "CHARLES",
        "credential": "MS, ATC, PA",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2010-05-25",
        "last_updated": "2024-07-23",
        "certification_date": "2024-07-23",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2255A2300X",
            "taxonomy_group": "",
            "desc": "Specialist/Technologist, Athletic Trainer",
            "state": "MO",
            "license": "200901846",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "MO",
            "license": "2018004459",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "220051288",
            "state": "MO"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1083933485",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Lebanon, MO

Sources for this page

Verify at the official NPI Registry.