Provider Demographics
NPI:1023755824
Name:WARD, BRANDON
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:WARD
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 1:6638 S 57TH AVE
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-2254
Mailing Address - Country:US
Mailing Address - Phone:602-346-0081
Mailing Address - Fax:
Practice Address - Street 1:6638 S 57TH AVE
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-2254
Practice Address - Country:US
Practice Address - Phone:602-346-0081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-13
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ107512Medicaid