Healthcare Provider Details

I. General information

NPI: 1124236245
Provider Name (Legal Business Name): BRADLEY JOHN BUSH N.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 05/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 NEW ENGLAND PL SUITE 220
STILLWATER MN
55082-5783
US

IV. Provider business mailing address

105 NEW ENGLAND PL SUITE 220
STILLWATER MN
55082-5783
US

V. Phone/Fax

Practice location:
  • Phone: 651-342-1043
  • Fax:
Mailing address:
  • Phone: 651-342-1043
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number1010
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: