Provider Demographics
NPI:1841874609
Name:BRADFORD, GUS
Entity type:Individual
Prefix:
First Name:GUS
Middle Name:
Last Name:BRADFORD
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 1:4145 PARKLAWN AVE APT 222
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-4648
Mailing Address - Country:US
Mailing Address - Phone:952-851-8200
Mailing Address - Fax:
Practice Address - Street 1:3601 MINNESOTA DR STE 600
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-5248
Practice Address - Country:US
Practice Address - Phone:952-851-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-07
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant