Provider Demographics
NPI:1649277237
Name:ROBERTS, BRADLEY (ACNP-BC)
Entity type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:ACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5340 LEITH DR
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59106-4010
Mailing Address - Country:US
Mailing Address - Phone:406-409-0391
Mailing Address - Fax:
Practice Address - Street 1:5340 LEITH DR
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59106-4010
Practice Address - Country:US
Practice Address - Phone:406-702-5538
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTNUR-RN-LIC-23565163W00000X
MTRN23565363LA2100X
MTNUR-APRN-100295363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000374780OtherBCBS PIN
MT4305896OtherMDCD PIN
WY121017300OtherMDCD PIN
MTMR1141275OtherDEA NUMBER
MT000374780OtherBCBS PIN
WY121017300OtherMDCD PIN
MT1153260003Medicare PIN
MT4305896OtherMDCD PIN