Provider Demographics
NPI:1285675728
Name:STORK, BRADLEY R (NP-C)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:R
Last Name:STORK
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4515
Mailing Address - Country:US
Mailing Address - Phone:701-530-8800
Mailing Address - Fax:
Practice Address - Street 1:310 N 9TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4515
Practice Address - Country:US
Practice Address - Phone:701-530-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR27167363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1459578Medicaid
ND500018668OtherMEDICARE RAILROAD
ND500018668OtherMEDICARE RAILROAD
ND1459578Medicaid
ND19677Medicaid