Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 6430 | MN |
NPI | 1003222068 |
---|---|
Provider Name | Bradley Leafblad |
First Address | Woodbury, MN 55125-8409 |
Second Address | Woodbury, MN 55125-8409 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/07/2014 |
Last Update Date | 10/07/2014 |