Provider Demographics
NPI:1477157261
Name:YENTZER, BRAD PATRICK (RD)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:PATRICK
Last Name:YENTZER
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 8TH AVE SE APT A
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-2262
Mailing Address - Country:US
Mailing Address - Phone:651-373-5662
Mailing Address - Fax:
Practice Address - Street 1:221 8TH AVE SE APT A
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414-2262
Practice Address - Country:US
Practice Address - Phone:651-373-5662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4401133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered