Basic Information
| Provider Information | |||||||||
| NPI: | 1457547796 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KRUMM | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | C.N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7850 JEFFERSON ST NE STE 300 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871094314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058841114 | ||||||||
| FaxNumber: | 5058566320 | ||||||||
| Practice Location | |||||||||
| Address1: | 7850 JEFFERSON ST NE STE 300 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871094314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058841114 | ||||||||
| FaxNumber: | 5058566320 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2007 | ||||||||
| LastUpdateDate: | 07/14/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | R37050 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | CNP00804 | NM | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 32638221 | 05 | NM | MEDICAID |