=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265686398
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN HIGGERSON FNP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2008
-----------------------------------------------------
Last Update Date | 01/27/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 MADEIRA DR NE STE 220
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87108-1538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-323-0012
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 120 MADEIRA DR NE STE 220
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87108-1538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-323-0012
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 209-001187
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | CNP-01773
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------