Provider Demographics
NPI:1336117134
Name:BRUBAKER, MARY LOUISA (PA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOUISA
Last Name:BRUBAKER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3630
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86003-3630
Mailing Address - Country:US
Mailing Address - Phone:928-213-6121
Mailing Address - Fax:928-213-6136
Practice Address - Street 1:2920 N 4TH ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-1816
Practice Address - Country:US
Practice Address - Phone:928-213-6121
Practice Address - Fax:928-213-6136
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2368207Q00000X
AZ71081835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP60059Medicare UPIN