Provider Demographics
NPI:1659671980
Name:TETRAULT, BRANDON JAMES (ATC)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:JAMES
Last Name:TETRAULT
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:UNIVERSITY OF NORTH DAKOTA
Mailing Address - Street 2:1301 N COLUMBIA RD
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58202
Mailing Address - Country:US
Mailing Address - Phone:701-610-1060
Mailing Address - Fax:
Practice Address - Street 1:UNIVERSITY OF NORTH DAKOTA
Practice Address - Street 2:1301 N COLUMBIA RD
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58202-0001
Practice Address - Country:US
Practice Address - Phone:701-610-1060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-03
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND953-222255A2300X
MI26010010622255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer