Basic Information
| Provider Information | |||||||||
| NPI: | 1568187169 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MORTENSEN | ||||||||
| FirstName: | BRAYDEN | ||||||||
| MiddleName: | BRADLEY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5529 SUNLIGHT DR APT 205 | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277079057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8016735859 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5716 FAYETTEVILLE RD | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277139661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195721868 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2022 | ||||||||
| LastUpdateDate: | 10/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 5017006 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.