Provider Demographics
NPI:1558956375
Name:CROCKETT, BRANDON IRA
Entity Type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:IRA
Last Name:CROCKETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NM
Mailing Address - Zip Code:87413-6235
Mailing Address - Country:US
Mailing Address - Phone:505-330-8220
Mailing Address - Fax:505-234-7867
Practice Address - Street 1:101 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NM
Practice Address - Zip Code:87413-6235
Practice Address - Country:US
Practice Address - Phone:505-330-8220
Practice Address - Fax:505-234-7867
Is Sole Proprietor?:No
Enumeration Date:2021-03-03
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker