Healthcare Provider Details

I. General information

NPI: 1487394938
Provider Name (Legal Business Name): BRADLEY TAYLOR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2022
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 S SCHWARTZ AVE
FARMINGTON NM
87401-5955
US

IV. Provider business mailing address

PO BOX 844088
DALLAS TX
75284-4088
US

V. Phone/Fax

Practice location:
  • Phone: 505-609-6680
  • Fax: 505-609-2259
Mailing address:
  • Phone: 505-609-2258
  • Fax: 505-609-2259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberDO2026-0061
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: