Healthcare Provider Details

I. General information

NPI: 1336117134
Provider Name (Legal Business Name): MARY LOUISA BRUBAKER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 08/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2920 N 4TH ST
FLAGSTAFF AZ
86004-1816
US

IV. Provider business mailing address

PO BOX 3630
FLAGSTAFF AZ
86003-3630
US

V. Phone/Fax

Practice location:
  • Phone: 928-213-6121
  • Fax: 928-213-6136
Mailing address:
  • Phone: 928-213-6121
  • Fax: 928-213-6136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2368
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number7108
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: