Healthcare Provider Details

I. General information

NPI: 1942756630
Provider Name (Legal Business Name): MICHAEL R BRISON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2016
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 5TH ST STE A
SANTA FE NM
87505-6012
US

IV. Provider business mailing address

1919 5TH ST STE A
SANTA FE NM
87505-6012
US

V. Phone/Fax

Practice location:
  • Phone: 505-216-6387
  • Fax: 949-883-3768
Mailing address:
  • Phone: 505-216-6387
  • Fax: 949-883-3768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberCNP-03044
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: