Basic Information
| Provider Information | |||||||||
| NPI: | 1346413069 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADSTREET | ||||||||
| FirstName: | HARRY | ||||||||
| MiddleName: | CECIL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3851 ROGER BROOKE DR | ||||||||
| Address2: | |||||||||
| City: | FORT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782344501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109162460 | ||||||||
| FaxNumber: | 2109165102 | ||||||||
| Practice Location | |||||||||
| Address1: | 3851 ROGER BROOKE DR | ||||||||
| Address2: | |||||||||
| City: | FORT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782344501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109162460 | ||||||||
| FaxNumber: | 2109165102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2008 | ||||||||
| LastUpdateDate: | 04/03/2008 | ||||||||
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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 | 363LA2100X | 567335 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.