Healthcare Provider Details

I. General information

NPI: 1114392545
Provider Name (Legal Business Name): KRISTEN SCOTT BRADLEY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2015
Last Update Date: 06/27/2025
Certification Date: 06/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 NORTHLAND DR
BLOOMINGTON MN
55431
US

IV. Provider business mailing address

3031 EWING AVE S APT 319
MINNEAPOLIS MN
55416-4255
US

V. Phone/Fax

Practice location:
  • Phone: 952-831-8742
  • Fax:
Mailing address:
  • Phone: 651-272-0342
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1869
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: