Provider Demographics
NPI:1659948974
Name:GRAY, BRADLEY THOMAS (RN)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:THOMAS
Last Name:GRAY
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 156
Mailing Address - Street 2:
Mailing Address - City:GREY EAGLE
Mailing Address - State:MN
Mailing Address - Zip Code:56336-0156
Mailing Address - Country:US
Mailing Address - Phone:507-475-4354
Mailing Address - Fax:
Practice Address - Street 1:11114 ALMOND DR
Practice Address - Street 2:
Practice Address - City:GREY EAGLE
Practice Address - State:MN
Practice Address - Zip Code:56336-4643
Practice Address - Country:US
Practice Address - Phone:605-413-7349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-06
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN763648164W00000X
MN2493855163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse