Provider Demographics
NPI:1780328278
Name:BRONSON, MICHAEL LAMONT
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:LAMONT
Last Name:BRONSON
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 1:3822 SOURWOOD CT
Mailing Address - Street 2:
Mailing Address - City:LADSON
Mailing Address - State:SC
Mailing Address - Zip Code:29456-9604
Mailing Address - Country:US
Mailing Address - Phone:612-875-0142
Mailing Address - Fax:
Practice Address - Street 1:2512 E 38TH ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-3020
Practice Address - Country:US
Practice Address - Phone:612-433-1164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-21
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker