Provider Demographics
NPI:1568187169
Name:MORTENSEN, BRAYDEN BRADLEY
Entity Type:Individual
Prefix:
First Name:BRAYDEN
Middle Name:BRADLEY
Last Name:MORTENSEN
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 1:5529 SUNLIGHT DR APT 205
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-9057
Mailing Address - Country:US
Mailing Address - Phone:801-673-5859
Mailing Address - Fax:
Practice Address - Street 1:5716 FAYETTEVILLE RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-9661
Practice Address - Country:US
Practice Address - Phone:919-572-1868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-05
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5017006363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily