Provider Demographics
NPI:1487666111
Name:PROBST, BRADLEY E (MN FNP)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:E
Last Name:PROBST
Suffix:
Gender:M
Credentials:MN FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 S 336TH ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6328
Mailing Address - Country:US
Mailing Address - Phone:253-838-6180
Mailing Address - Fax:253-838-6418
Practice Address - Street 1:335 SE 8TH AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4246
Practice Address - Country:US
Practice Address - Phone:503-681-1176
Practice Address - Fax:503-681-1606
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
F0606263OtherAANP CERTIFICATION NP-C
F0606263OtherAANP CERTIFICATION NP-C
ORG137895Medicare PIN