Healthcare Provider Details

I. General information

NPI: 1770586034
Provider Name (Legal Business Name): MARION J BRATVOLD PA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 S MINNESOTA ST
WARREN MN
56762-1461
US

IV. Provider business mailing address

109 S MINNESOTA ST
WARREN MN
56762-1461
US

V. Phone/Fax

Practice location:
  • Phone: 218-745-4211
  • Fax: 218-745-4215
Mailing address:
  • Phone: 218-745-4211
  • Fax: 218-745-4215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9431
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: