Basic Information
| Provider Information | |||||||||
| NPI: | 1790144558 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADLEY | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 249 WILLIAMSON RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | MOORESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281178195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043604564 | ||||||||
| FaxNumber: | 7043604553 | ||||||||
| Practice Location | |||||||||
| Address1: | 249 WILLIAMSON RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | MOORESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281178195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043604564 | ||||||||
| FaxNumber: | 7043604553 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2016 | ||||||||
| LastUpdateDate: | 03/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 001006280 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 001006280 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 0010-06280 | 01 | NC | NC LICENSE | OTHER |