MEDICARE: MR. BRADLEY ROBERTS ACNP-BC

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	163W00000X	Registered Nurse	NUR-RN-LIC-23565	MT
2	363LA2100X	Acute Care Nurse Practitioner	RN23565	MT
3	363LA2100X	Acute Care Nurse Practitioner	NUR-APRN-100295	MT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000374780	OTHER	MT	BCBS PIN
2	4305896	OTHER	MT	MDCD PIN
3	121017300	OTHER	WY	MDCD PIN

General Provider Information

NPI Number	:	1649277237
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRADLEY ROBERTS ACNP-BC

Provider Business Mailing Address
First Line	:	5340 LEITH DR
Second Line	:
City	:	BILLINGS
State	:	MT
Zip	:	59106-4010
Country	:	US
Telephone Number	:	406-409-0391
Fax Number	:

Provider Business Practice Location Address
First Line	:	5340 LEITH DR
Second Line	:
City	:	BILLINGS
State	:	MT
Zip	:	59106-4010
Country	:	US
Telephone Number	:	406-702-5538
Fax Number	:

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

Provider Enumeration Date	:	06/28/2005
Last Update Date	:	03/07/2023

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