Basic Information
| Provider Information | |||||||||
| NPI: | 1942756630 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRISON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | RYAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26028 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871256028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052627110 | ||||||||
| FaxNumber: | 5052627308 | ||||||||
| Practice Location | |||||||||
| Address1: | 2901 TRANSPORT ST SE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052627110 | ||||||||
| FaxNumber: | 5052627308 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2016 | ||||||||
| LastUpdateDate: | 05/03/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | CNP-03044 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 62851764 | 05 | NM | MEDICAID |