Basic Information
| Provider Information | |||||||||
| NPI: | 1306895321 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRAGDON | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 90 PRESIDENTIAL PLZ | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132022240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154644243 | ||||||||
| FaxNumber: | 3154645350 | ||||||||
| Practice Location | |||||||||
| Address1: | 90 PRESIDENTIAL PLZ | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132022240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154644243 | ||||||||
| FaxNumber: | 3154645350 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 05/06/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 178406 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0600X | 178406 | NY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology |
ID Information
| ID | Type | State | Issuer | Description | 01137439 | 05 | NY | MEDICAID |