Provider Demographics
NPI:1659165017
Name:HERTZOG, BRAD MATTHEW
Entity type:Individual
Prefix:
First Name:BRAD
Middle Name:MATTHEW
Last Name:HERTZOG
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 1:21825 E QUINCY AVE
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80018-3155
Mailing Address - Country:US
Mailing Address - Phone:970-988-0838
Mailing Address - Fax:
Practice Address - Street 1:21825 E QUINCY AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80018-3155
Practice Address - Country:US
Practice Address - Phone:970-988-0838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-08
Last Update Date:2025-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY57166363LP0808X
CORN.1639037163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine