Provider Demographics
NPI:1366461873
Name:DANIELSON, BRET M (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BRET
Middle Name:M
Last Name:DANIELSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:CROSBY
Mailing Address - State:MN
Mailing Address - Zip Code:56441
Mailing Address - Country:US
Mailing Address - Phone:218-546-7000
Mailing Address - Fax:218-546-4400
Practice Address - Street 1:30833 NORTH STAR DR, STE 1
Practice Address - Street 2:
Practice Address - City:BREEZY POINT
Practice Address - State:MN
Practice Address - Zip Code:56472-4407
Practice Address - Country:US
Practice Address - Phone:218-568-4926
Practice Address - Fax:218-546-4400
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0351363AM0700X
MN10241363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND28514OtherBSND @ KULM
ND28515OtherBSND @ NAPOLEON
ND28516OtherBSND @ GACKLE
ND28513OtherBSND @ WISHEK
ND28515OtherBSND @ NAPOLEON