1962628156 NPI number — MS. BRENDA A BROUSSARD RD, CDE, BC-ADM

Table of content: MS. BRENDA A BROUSSARD RD, CDE, BC-ADM (NPI 1962628156)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962628156 NPI number — MS. BRENDA A BROUSSARD RD, CDE, BC-ADM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROUSSARD
Provider First Name:
BRENDA
Provider Middle Name:
A
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
RD, CDE, BC-ADM
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:
1962628156
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18 BERM ST NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87120-1822
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-792-0065
Provider Business Mailing Address Fax Number:
505-792-0488

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
PRESBYTERIAN FAMILY PRACTICE MEDICAL GROUP
Provider Second Line Business Practice Location Address:
3901 ATRISCO
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-462-7575
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/17/2007

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: 133VN1006X , with the licence number:  036 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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