Provider Demographics
NPI:1033137872
Name:BRATRUD, RANDY M (PT)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:M
Last Name:BRATRUD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2251 N 32ND ST
Mailing Address - Street 2:LOT #7
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-2423
Mailing Address - Country:US
Mailing Address - Phone:480-830-2045
Mailing Address - Fax:
Practice Address - Street 1:2251 N 32ND ST
Practice Address - Street 2:LOT #7
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85213-2423
Practice Address - Country:US
Practice Address - Phone:480-830-2045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0815225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ76390Medicare PIN
AZ4920680001Medicare NSC
AZ119978Medicare PIN