Basic Information
| Provider Information | |||||||||
| NPI: | 1043253149 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOLF | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 BELLEFONTAINE AVE | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458042800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199984575 | ||||||||
| FaxNumber: | 4199984586 | ||||||||
| Practice Location | |||||||||
| Address1: | 1003 BELLEFONTAINE AVE STE 125 | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458041867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199988207 | ||||||||
| FaxNumber: | 4199988216 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 05/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 004685 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 50.006426RX | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.