Provider Demographics
NPI:1326470949
Name:VAN TASSEL, BRADLEY DAVID
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:DAVID
Last Name:VAN TASSEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15378 FOSTER DR N
Mailing Address - Street 2:
Mailing Address - City:HUGO
Mailing Address - State:MN
Mailing Address - Zip Code:55038-8544
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:445 GALTIER ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55103-2358
Practice Address - Country:US
Practice Address - Phone:651-224-1848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-06
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9158A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant