Provider Demographics
NPI:1578751673
Name:BROWN, BRUCE GERALD
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:GERALD
Last Name:BROWN
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 1:525 S LAKE AVE
Mailing Address - Street 2:SUITE 222
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-2362
Mailing Address - Country:US
Mailing Address - Phone:218-740-4608
Mailing Address - Fax:218-722-2390
Practice Address - Street 1:525 S LAKE AVE
Practice Address - Street 2:SUITE 222
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-2362
Practice Address - Country:US
Practice Address - Phone:218-740-4608
Practice Address - Fax:218-722-2390
Is Sole Proprietor?:No
Enumeration Date:2007-10-15
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 140152-7163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse