Basic Information
Provider Information | |||||||||
NPI: | 1740209014 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NOON | ||||||||
FirstName: | BRADLEY | ||||||||
MiddleName: | ROY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1225 E LATHAM AVE | ||||||||
Address2: | STE A | ||||||||
City: | HEMET | ||||||||
State: | CA | ||||||||
PostalCode: | 925434423 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9516528700 | ||||||||
FaxNumber: | 9517669944 | ||||||||
Practice Location | |||||||||
Address1: | 1225 E LATHAM AVE | ||||||||
Address2: | STE A | ||||||||
City: | HEMET | ||||||||
State: | CA | ||||||||
PostalCode: | 925434423 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9516528700 | ||||||||
FaxNumber: | 9517669944 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/18/2006 | ||||||||
LastUpdateDate: | 07/08/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | H62948 | GA | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
ID | Type | State | Issuer | Description | 017732 | 01 | GA | BLUE CROSS BLUE SHIELD | OTHER | 000962794A | 05 | GA |   | MEDICAID |