MEDICARE: BRAD MATTHEW HERTZOG

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	57166	WY
2	163WC0200X	Critical Care Medicine Registered Nurse	RN.1639037	CO

General Provider Information

NPI Number	:	1659165017
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRAD MATTHEW HERTZOG

Provider Business Mailing Address
First Line	:	21825 E QUINCY AVE
Second Line	:
City	:	AURORA
State	:	CO
Zip	:	80018-3155
Country	:	US
Telephone Number	:	970-988-0838
Fax Number	:

Provider Business Practice Location Address
First Line	:	21825 E QUINCY AVE
Second Line	:
City	:	AURORA
State	:	CO
Zip	:	80018-3155
Country	:	US
Telephone Number	:	970-988-0838
Fax Number	:

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

Provider Enumeration Date	:	04/08/2025
Last Update Date	:	10/16/2025

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Directions to “ BRAD MATTHEW HERTZOG ” Practice Location

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