Healthcare Provider Details

I. General information

NPI: 1326047846
Provider Name (Legal Business Name): WILLIAM BRANT HESIDENCE II DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 02/16/2023
Certification Date: 02/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 E NIZHONI BLVD
GALLUP NM
87301-5757
US

IV. Provider business mailing address

511 E NIZHONI BLVD
GALLUP NM
87301-5757
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number257
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPD0103
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO 2948
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO2948
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: