1366723272 NPI number — JEANETTE BRADFORD GUNDERSON OTR

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366723272 NPI number — JEANETTE BRADFORD GUNDERSON OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUNDERSON
Provider First Name:
JEANETTE
Provider Middle Name:
BRADFORD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366723272
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7250 FRANCE AVE S
Provider Second Line Business Mailing Address:
SUITE 305
Provider Business Mailing Address City Name:
EDINA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55435-4305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-285-2840
Provider Business Mailing Address Fax Number:
952-285-2830

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7250 FRANCE AVE S
Provider Second Line Business Practice Location Address:
SUITE 305
Provider Business Practice Location Address City Name:
EDINA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55435-4305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-285-2840
Provider Business Practice Location Address Fax Number:
952-285-2830
Provider Enumeration Date:
09/06/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225XP0200X , with the licence number:  101544 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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