Basic Information
Provider Information | |||||||||
NPI: | 1437565272 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STUCKY | ||||||||
FirstName: | BRADLEY | ||||||||
MiddleName: | KEITH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 913041 | ||||||||
Address2: |   | ||||||||
City: | DENVER | ||||||||
State: | CO | ||||||||
PostalCode: | 802913041 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6105945108 | ||||||||
FaxNumber: | 6103631790 | ||||||||
Practice Location | |||||||||
Address1: | 911 N MAIN ST | ||||||||
Address2: |   | ||||||||
City: | GARDEN CITY | ||||||||
State: | KS | ||||||||
PostalCode: | 67846 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6202768201 | ||||||||
FaxNumber: | 6202768739 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/01/2014 | ||||||||
LastUpdateDate: | 08/03/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 94-08514 | KS | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 05-39002 | KS | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.