Healthcare Provider Details

I. General information

NPI: 1750074480
Provider Name (Legal Business Name): BRANDIN COLE SPADY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2023
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19021 US HIGHWAY 285
LA JARA CO
81140-9410
US

IV. Provider business mailing address

3269 N STOCKTON HILL RD
KINGMAN AZ
86409-3619
US

V. Phone/Fax

Practice location:
  • Phone: 719-274-5121
  • Fax:
Mailing address:
  • Phone: 928-757-2101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberR4160
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberDR.0077099
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: