Healthcare Provider Details

I. General information

NPI: 1740163922
Provider Name (Legal Business Name): BRANDON MICHAEL BLACK RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2025
Last Update Date: 07/28/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 MENAUL BLVD NE
ALBUQUERQUE NM
87107-1642
US

IV. Provider business mailing address

1111 CARRIZO ST NW
LOS LUNAS NM
87031-6934
US

V. Phone/Fax

Practice location:
  • Phone: 575-621-8918
  • Fax:
Mailing address:
  • Phone: 575-621-8918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN-90590
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code163WF0300X
TaxonomyFlight Registered Nurse
License NumberRN-90590
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberRN-90590
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: