Provider Demographics
NPI:1710371604
Name:ROMERO ALEJANDRE, BRISEIDA
Entity Type:Individual
Prefix:
First Name:BRISEIDA
Middle Name:
Last Name:ROMERO ALEJANDRE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:559 VINCENT ST
Mailing Address - Street 2:ATTN: 21 MDOS/SGOF- FAMILY MEDICINE
Mailing Address - City:PETERSON AFB
Mailing Address - State:CO
Mailing Address - Zip Code:80914-1540
Mailing Address - Country:US
Mailing Address - Phone:719-567-4162
Mailing Address - Fax:
Practice Address - Street 1:1338 PHAY AVE
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-2311
Practice Address - Country:US
Practice Address - Phone:719-285-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-27
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52317363A00000X
COPA.0004916363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant