Provider Demographics
NPI:1730132127
Name:GOODROAD, BRIAN KEITH (CNP)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:KEITH
Last Name:GOODROAD
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 PARK AVE
Mailing Address - Street 2:B1.290
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55415-1623
Mailing Address - Country:US
Mailing Address - Phone:612-873-2700
Mailing Address - Fax:612-904-4440
Practice Address - Street 1:701 PARK AVE
Practice Address - Street 2:B1.290
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55415-1623
Practice Address - Country:US
Practice Address - Phone:612-873-2700
Practice Address - Fax:612-904-4440
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1051731363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN722520200Medicare ID - Type Unspecified
MNS12320Medicare UPIN