Basic Information
| Provider Information | |||||||||
| NPI: | 1578183968 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRADLEY | ||||||||
| FirstName: | ROBERT | ||||||||
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| Credential: | APRN-CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3701 SIERRA VISTA DR | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 874028356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4055745715 | ||||||||
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| Practice Location | |||||||||
| Address1: | 525 S SCHWARTZ AVE | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 874015955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5056092000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2020 | ||||||||
| LastUpdateDate: | 04/26/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 53-78499-102 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 53-78499-102 | 01 | KS | KANSAS STATE BOARD OF NURSING | OTHER |