Provider Demographics
NPI:1013576982
Name:GROSS, BRADY MICHAEL (MPAS)
Entity Type:Individual
Prefix:
First Name:BRADY
Middle Name:MICHAEL
Last Name:GROSS
Suffix:
Gender:M
Credentials:MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 LYMAN CT NE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:MN
Mailing Address - Zip Code:55967-8823
Mailing Address - Country:US
Mailing Address - Phone:507-216-2540
Mailing Address - Fax:
Practice Address - Street 1:2200 NW 26TH ST
Practice Address - Street 2:
Practice Address - City:OWATONNA
Practice Address - State:MN
Practice Address - Zip Code:55060-5503
Practice Address - Country:US
Practice Address - Phone:507-451-1120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-13
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
MN13269363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant