Healthcare Provider Details

I. General information

NPI: 1326470949
Provider Name (Legal Business Name): BRADLEY DAVID VAN TASSEL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2013
Last Update Date: 08/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 GALTIER ST
SAINT PAUL MN
55103-2358
US

IV. Provider business mailing address

15378 FOSTER DR N
HUGO MN
55038-8544
US

V. Phone/Fax

Practice location:
  • Phone: 651-224-1848
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number9158A
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: