Provider Demographics
NPI:1831616689
Name:MADRID, BRENDON (NP)
Entity type:Individual
Prefix:
First Name:BRENDON
Middle Name:
Last Name:MADRID
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4112 OUTLOOK BLVD STE 325
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-1667
Mailing Address - Country:US
Mailing Address - Phone:719-562-6300
Mailing Address - Fax:
Practice Address - Street 1:4112 OUTLOOK BLVD STE 325
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1667
Practice Address - Country:US
Practice Address - Phone:719-562-6300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-23
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO000000000363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner