Provider Demographics
NPI:1790789477
Name:BRICKSON, MARCIA (FNP)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:
Last Name:BRICKSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13611 N 79TH LN
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4101
Mailing Address - Country:US
Mailing Address - Phone:623-486-3403
Mailing Address - Fax:623-486-3403
Practice Address - Street 1:13611 N 79TH LN
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4101
Practice Address - Country:US
Practice Address - Phone:623-486-3403
Practice Address - Fax:623-486-3403
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN088180207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP30473Medicare UPIN