Healthcare Provider Details

I. General information

NPI: 1770559239
Provider Name (Legal Business Name): BRADLEY H RUTTEN PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 12/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2251 CONNECTICUT AVE S
SARTELL MN
56377-2486
US

IV. Provider business mailing address

2251 CONNECTICUT AVE S
SARTELL MN
56377-2486
US

V. Phone/Fax

Practice location:
  • Phone: 320-253-5220
  • Fax: 320-203-2113
Mailing address:
  • Phone: 320-253-5220
  • Fax: 320-203-2113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9022
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: