Provider Demographics
NPI:1770559239
Name:RUTTEN, BRADLEY H (PAC)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:H
Last Name:RUTTEN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2251 CONNECTICUT AVE S
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-2486
Mailing Address - Country:US
Mailing Address - Phone:320-253-5220
Mailing Address - Fax:320-203-2113
Practice Address - Street 1:2251 CONNECTICUT AVE S
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-2486
Practice Address - Country:US
Practice Address - Phone:320-253-5220
Practice Address - Fax:320-203-2113
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2015-12-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN9022363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN472752500Medicaid
R04652Medicare UPIN