Provider Demographics
NPI:1679594592
Name:FRADETTE, BRIAN R (DPM)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:R
Last Name:FRADETTE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 TSIENNETO RD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:DERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03038-1584
Mailing Address - Country:US
Mailing Address - Phone:603-432-2508
Mailing Address - Fax:603-432-2008
Practice Address - Street 1:6 TSIENNETO RD
Practice Address - Street 2:SUITE 303
Practice Address - City:DERRY
Practice Address - State:NH
Practice Address - Zip Code:03038-1584
Practice Address - Country:US
Practice Address - Phone:603-432-2508
Practice Address - Fax:603-432-2008
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-23
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NHNH0149213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH80488249Medicaid
NH0540820001Medicare NSC
NHT25727Medicare UPIN
NH80488249Medicaid