=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114579612
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRADLEY KLEIN APNP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2019
-----------------------------------------------------
Last Update Date | 08/15/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 710 RIVERSIDE DR
-----------------------------------------------------
City | WAUPACA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54981-1941
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-256-3000
-----------------------------------------------------
Fax | 715-256-3079
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 122 E COLLEGE AVE
-----------------------------------------------------
City | APPLETON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54911-5794
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-996-3264
-----------------------------------------------------
Fax | 920-830-5910
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 9425
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------