Provider Demographics
NPI:1740163922
Name:BLACK, BRANDON MICHAEL (RN)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:MICHAEL
Last Name:BLACK
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 CARRIZO ST NW
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-6934
Mailing Address - Country:US
Mailing Address - Phone:575-621-8918
Mailing Address - Fax:
Practice Address - Street 1:1001 MENAUL BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-1642
Practice Address - Country:US
Practice Address - Phone:575-621-8918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-28
Last Update Date:2025-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRN-90590163WC0200X, 163WF0300X, 163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No163WF0300XNursing Service ProvidersRegistered NurseFlight