Healthcare Provider Details

I. General information

NPI: 1245823558
Provider Name (Legal Business Name): BRIAN RUSSELL DIEDRICH CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2021
Last Update Date: 02/17/2021
Certification Date: 02/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 S CHAMISA DR
SANTA FE NM
87508-9149
US

IV. Provider business mailing address

23 S CHAMISA DR
SANTA FE NM
87508-9149
US

V. Phone/Fax

Practice location:
  • Phone: 303-506-7260
  • Fax:
Mailing address:
  • Phone: 303-506-7260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number62824
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: