Basic Information
| Provider Information | |||||||||
| NPI: | 1871660555 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADLEY | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | C. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 18139 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276198139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6365492380 | ||||||||
| FaxNumber: | 3145695974 | ||||||||
| Practice Location | |||||||||
| Address1: | 9104 MARKET ST | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284117994 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016943400 | ||||||||
| FaxNumber: | 3016943620 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2006 | ||||||||
| LastUpdateDate: | 04/30/2011 | ||||||||
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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 | 367500000X | R118379 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | KBC1CH | 01 | MD | CAREFIRST BCBS | OTHER | P00728709 | 01 | MD | MEDICARE RAILROAD (GRP PTAN CJ8689) | OTHER | R118379 | 01 | MD | LICENSE | OTHER | S417 0030 | 01 | DC | CAREFIRST BCBS | OTHER | 403621200 | 05 | MD | MEDICAID | P00745073 | 01 | MD | MEDICARE RAILROAD (GRP PTAN DD6120) | OTHER |