Provider Demographics
NPI:1477022317
Name:MCDONALD, BRIAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:MCDONALD
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 1:9298 CENTRAL AVE NE STE 202
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-4217
Mailing Address - Country:US
Mailing Address - Phone:763-205-4440
Mailing Address - Fax:763-205-4403
Practice Address - Street 1:9298 CENTRAL AVE NE STE 202
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-4217
Practice Address - Country:US
Practice Address - Phone:763-205-4440
Practice Address - Fax:763-205-4403
Is Sole Proprietor?:No
Enumeration Date:2018-11-21
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN387743163WH0200X, 372600000X, 3747P1801X, 374U00000X, 376J00000X, 376K00000X
MN394396374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No372600000XNursing Service Related ProvidersAdult Companion
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No376J00000XNursing Service Related ProvidersHomemaker
No376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN397396OtherMN DEPARTMENT OF HEALTH LICENSE