Provider Demographics
NPI:1184165276
Name:MALBROUGH, BRADY D (NP)
Entity type:Individual
Prefix:
First Name:BRADY
Middle Name:D
Last Name:MALBROUGH
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 123690
Mailing Address - Street 2:DEPT. 3690
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75312-3690
Mailing Address - Country:US
Mailing Address - Phone:855-686-8430
Mailing Address - Fax:904-265-8181
Practice Address - Street 1:602 N ACADIA RD
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-4823
Practice Address - Country:US
Practice Address - Phone:985-447-5500
Practice Address - Fax:904-265-8181
Is Sole Proprietor?:No
Enumeration Date:2017-03-09
Last Update Date:2017-03-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
LAAP09161363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner