Basic Information
| Provider Information | |||||||||
| NPI: | 1548546435 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADLEY | ||||||||
| FirstName: | BENJAMIN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 305 EAST CENTER AVE. | ||||||||
| Address2: | |||||||||
| City: | VISALIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932916331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5597374700 | ||||||||
| FaxNumber: | 5597374782 | ||||||||
| Practice Location | |||||||||
| Address1: | 12586 AVENUE 408 | ||||||||
| Address2: | |||||||||
| City: | CUTLER/OROSI | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936479454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5595282804 | ||||||||
| FaxNumber: | 5595287623 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2011 | ||||||||
| LastUpdateDate: | 12/21/2011 | ||||||||
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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 | 363A00000X | PA21965 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA21965 | 01 | CA | LICENSE | OTHER |