Healthcare Provider Details

I. General information

NPI: 1700328689
Provider Name (Legal Business Name): BRADY PERRY GRIFFITH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2016
Last Update Date: 05/19/2023
Certification Date: 05/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S MAPLE ST
WACONIA MN
55387-1752
US

IV. Provider business mailing address

8959 PARTRIDGE RD
SAINT BONIFACIUS MN
55375-1320
US

V. Phone/Fax

Practice location:
  • Phone: 952-442-2191
  • Fax: 952-442-6537
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number12320
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12320
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: