Provider Demographics
NPI:1457968687
Name:BROSSARD, BRADLEY RICHARD (NP-C)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:RICHARD
Last Name:BROSSARD
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 DEWEY ST
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54494-4715
Mailing Address - Country:US
Mailing Address - Phone:715-423-6060
Mailing Address - Fax:
Practice Address - Street 1:410 DEWEY ST
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-4715
Practice Address - Country:US
Practice Address - Phone:608-289-5228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-01
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10458-33363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner