MEDICARE: BRAYDEN BRADLEY MORTENSEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	5017006	NC

General Provider Information

NPI Number	:	1568187169
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRAYDEN BRADLEY MORTENSEN

Provider Business Mailing Address
First Line	:	5529 SUNLIGHT DR APT 205
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27707-9057
Country	:	US
Telephone Number	:	801-673-5859
Fax Number	:

Provider Business Practice Location Address
First Line	:	5716 FAYETTEVILLE RD
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27713-9661
Country	:	US
Telephone Number	:	919-572-1868
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/05/2022
Last Update Date	:	10/05/2022

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