Provider Demographics
NPI:1225079338
Name:BRANDT, PENNY SUE (DO)
Entity Type:Individual
Prefix:MS
First Name:PENNY
Middle Name:SUE
Last Name:BRANDT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:DEPT OF PEDIATRICS
Mailing Address - Street 2:MSC 105590 1 UNM
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87131-0001
Mailing Address - Country:US
Mailing Address - Phone:505-272-5551
Mailing Address - Fax:505-272-2374
Practice Address - Street 1:DEPT OF PEDIATRICS
Practice Address - Street 2:MSC 105590 1 UNM
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-0001
Practice Address - Country:US
Practice Address - Phone:505-272-5551
Practice Address - Fax:505-272-2374
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NMA136506208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM33233Medicaid
NM33233Medicaid