Healthcare Provider Details

I. General information

NPI: 1083008924
Provider Name (Legal Business Name): BRADLEY EUGENE NELSON CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2015
Last Update Date: 05/10/2022
Certification Date: 05/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 SHINGLE CREEK PKWY STE 250
BROOKLYN CENTER MN
55430-2107
US

IV. Provider business mailing address

6200 SHINGLE CREEK PKWY STE 250
BROOKLYN CENTER MN
55430-2107
US

V. Phone/Fax

Practice location:
  • Phone: 763-544-0696
  • Fax: 763-544-0696
Mailing address:
  • Phone: 763-544-0696
  • Fax: 763-544-0696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number8806
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberF307678
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number671723
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: