Healthcare Provider Details

I. General information

NPI: 1831616689
Provider Name (Legal Business Name): BRENDON MADRID NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2017
Last Update Date: 08/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4112 OUTLOOK BLVD STE 325
PUEBLO CO
81008-1667
US

IV. Provider business mailing address

4112 OUTLOOK BLVD STE 325
PUEBLO CO
81008-1667
US

V. Phone/Fax

Practice location:
  • Phone: 719-562-6300
  • Fax:
Mailing address:
  • Phone: 719-562-6300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number000000000
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: