Basic Information
| Provider Information | |||||||||
| NPI: | 1699314286 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRAZILL | ||||||||
| FirstName: | ASHLEY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2118 DEER TRAIL LOOP NE | ||||||||
| Address2: | |||||||||
| City: | RIO RANCHO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871242475 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 6565 AMERICAS PKWY NE STE 200 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871108172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662732451 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2019 | ||||||||
| LastUpdateDate: | 12/30/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/30/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.