Provider Demographics
NPI:1114308426
Name:EKSTROM, BRANDI (COA, ST)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:
Last Name:EKSTROM
Suffix:
Gender:F
Credentials:COA, ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 E GLENDALE AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-5505
Mailing Address - Country:US
Mailing Address - Phone:602-242-4928
Mailing Address - Fax:602-249-4813
Practice Address - Street 1:1750 E GLENDALE AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-5505
Practice Address - Country:US
Practice Address - Phone:602-242-4928
Practice Address - Fax:602-249-4813
Is Sole Proprietor?:No
Enumeration Date:2015-06-11
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ159165OtherJCAHPO