Basic Information
| Provider Information | |||||||||
| NPI: | 1023085255 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRAVO | ||||||||
| FirstName: | WADE | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1381 S PATRICK DRIVE | ||||||||
| Address2: | 45TH MEDICAL GROUP | ||||||||
| City: | PATRICK AFB | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3214948159 | ||||||||
| FaxNumber: | 3214941378 | ||||||||
| Practice Location | |||||||||
| Address1: | 1381 S PATRICK DRIVE | ||||||||
| Address2: | 45TH MEDICAL GROUP | ||||||||
| City: | PATRICK AFB | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3214948159 | ||||||||
| FaxNumber: | 3214941378 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA2830 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.