Provider Demographics
NPI:1861568024
Name:BRAATEN, MARY MARGARET
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:MARGARET
Last Name:BRAATEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 10TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:DEER RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:56636-8703
Mailing Address - Country:US
Mailing Address - Phone:218-246-8275
Mailing Address - Fax:
Practice Address - Street 1:1025 10TH AVE NE
Practice Address - Street 2:
Practice Address - City:DEER RIVER
Practice Address - State:MN
Practice Address - Zip Code:56636-8703
Practice Address - Country:US
Practice Address - Phone:218-246-8275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN45933207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN874699100Medicaid
MN874699100Medicaid
G59343Medicare UPIN