Healthcare Provider Details

I. General information

NPI: 1003015314
Provider Name (Legal Business Name): MICHELLE RENAE BRADLEY DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4110 51ST AVE S
FARGO ND
58104-7776
US

IV. Provider business mailing address

1702 SOUTH UNIVERSITY DRIVE
FARGO ND
58103-4940
US

V. Phone/Fax

Practice location:
  • Phone: 701-364-3100
  • Fax:
Mailing address:
  • Phone: 701-364-3100
  • Fax: 320-202-0756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number52168
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberPT14577
License Number StateND
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number14577
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: