Basic Information
| Provider Information | |||||||||
| NPI: | 1669877387 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENNINGSGAARD | ||||||||
| FirstName: | BRADLEY | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5345 SILVER MOON LN | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276064534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124261814 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2301 ERWIN RD DEPARTMENT OF RADIOLOGY | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277101645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196847284 | ||||||||
| FaxNumber: | 9196132680 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2014 | ||||||||
| LastUpdateDate: | 02/24/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0010-06919 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.