Provider Demographics
NPI:1003015314
Name:BRADLEY, MICHELLE RENAE (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:RENAE
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1702 SOUTH UNIVERSITY DRIVE
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-4940
Mailing Address - Country:US
Mailing Address - Phone:701-364-3100
Mailing Address - Fax:320-202-0756
Practice Address - Street 1:4110 51ST AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-7776
Practice Address - Country:US
Practice Address - Phone:701-364-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN52168207Q00000X
NDPT14577207Q00000X
ND14577207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN036940100Medicaid
MN036940100Medicaid