Provider Demographics
NPI:1932420379
Name:MACBRAYNE, MICHAEL (PMHNP-BC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:MACBRAYNE
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13395 N MARANA MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARANA
Mailing Address - State:AZ
Mailing Address - Zip Code:85653-7008
Mailing Address - Country:US
Mailing Address - Phone:520-682-4111
Mailing Address - Fax:
Practice Address - Street 1:5224 W DOVE CENTRE RD
Practice Address - Street 2:
Practice Address - City:MARANA
Practice Address - State:AZ
Practice Address - Zip Code:85658-5063
Practice Address - Country:US
Practice Address - Phone:520-616-1445
Practice Address - Fax:520-616-1446
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-21
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010019097101Y00000X
AZAP9909363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ246176Medicaid