Healthcare Provider Details

I. General information

NPI: 1760352272
Provider Name (Legal Business Name): BRADY BAHNEMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2025
Last Update Date: 01/06/2026
Certification Date: 01/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4464 RALSTON DR
DULUTH MN
55811-1519
US

IV. Provider business mailing address

4464 RALSTON DR
DULUTH MN
55811-1519
US

V. Phone/Fax

Practice location:
  • Phone: 218-722-8634
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number13572
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: