Provider Demographics
NPI:1942756630
Name:BRISON, MICHAEL R
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:BRISON
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:PO BOX 26028
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6028
Mailing Address - Country:US
Mailing Address - Phone:505-262-7110
Mailing Address - Fax:505-262-7308
Practice Address - Street 1:2901 TRANSPORT ST SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106
Practice Address - Country:US
Practice Address - Phone:505-262-7110
Practice Address - Fax:505-262-7308
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-31
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-03044363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM62851764Medicaid