Basic Information
| Provider Information | |||||||||
| NPI: | 1487733192 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PICKETT | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | P. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1650 UNIVERSITY BLVD NE | ||||||||
| Address2: | SUITE 116 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871021726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052728950 | ||||||||
| FaxNumber: | 5052723202 | ||||||||
| Practice Location | |||||||||
| Address1: | 2211 LOMAS BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871062745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052728950 | ||||||||
| FaxNumber: | 5052723202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2006 | ||||||||
| LastUpdateDate: | 05/07/2018 | ||||||||
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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 | 207YX0905X | 97-34 | NM | N | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngology/Facial Plastic Surgery | 207Y00000X | 97-34 | NM | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207YX0901X | 97-341 | NM | Y | Allopathic & Osteopathic Physicians | Otolaryngology | Otology & Neurotology |
ID Information
| ID | Type | State | Issuer | Description | 384941 | 05 | AZ | MEDICAID | Q2517 | 05 | NM | MEDICAID |