Provider Demographics
NPI:1386631141
Name:NIESET, BRAD ALLEN (MD)
Entity type:Individual
Prefix:
First Name:BRAD
Middle Name:ALLEN
Last Name:NIESET
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6010
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59406-6010
Mailing Address - Country:US
Mailing Address - Phone:406-455-5000
Mailing Address - Fax:
Practice Address - Street 1:1645 VANDELAY AVE STE 301
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-3929
Practice Address - Country:US
Practice Address - Phone:406-389-2520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT12203207Q00000X
OH35080366207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2311984Medicaid
OHH57699Medicare UPIN
OHNI4087682Medicare PIN