Basic Information
Provider Information | |||||||||
NPI: | 1366461873 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DANIELSON | ||||||||
FirstName: | BRET | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 320 EAST MAIN STREET | ||||||||
Address2: |   | ||||||||
City: | CROSBY | ||||||||
State: | MN | ||||||||
PostalCode: | 56441 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2185467000 | ||||||||
FaxNumber: | 2185464400 | ||||||||
Practice Location | |||||||||
Address1: | 30833 NORTH STAR DR, STE 1 | ||||||||
Address2: |   | ||||||||
City: | BREEZY POINT | ||||||||
State: | MN | ||||||||
PostalCode: | 564724407 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2185684926 | ||||||||
FaxNumber: | 2185464400 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/18/2006 | ||||||||
LastUpdateDate: | 11/19/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/19/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PAC0351 | ND | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 10241 | MN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
ID | Type | State | Issuer | Description | 28514 | 01 | ND | BSND @ KULM | OTHER | 28515 | 01 | ND | BSND @ NAPOLEON | OTHER | 28516 | 01 | ND | BSND @ GACKLE | OTHER | 28513 | 01 | ND | BSND @ WISHEK | OTHER |