MEDICARE: BRANDON MICHAEL BLACK RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WC0200X	Critical Care Medicine Registered Nurse	RN-90590	NM
2	163WF0300X	Flight Registered Nurse	RN-90590	NM
3	163WE0003X	Emergency Registered Nurse	RN-90590	NM

General Provider Information

NPI Number	:	1740163922
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDON MICHAEL BLACK RN

Provider Business Mailing Address
First Line	:	1111 CARRIZO ST NW
Second Line	:
City	:	LOS LUNAS
State	:	NM
Zip	:	87031-6934
Country	:	US
Telephone Number	:	575-621-8918
Fax Number	:

Provider Business Practice Location Address
First Line	:	1001 MENAUL BLVD NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87107-1642
Country	:	US
Telephone Number	:	575-621-8918
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/28/2025
Last Update Date	:	07/28/2025

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