Provider Demographics
NPI:1033263603
Name:BRADFORD, DOUGLAS KEITH (CRNA)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:KEITH
Last Name:BRADFORD
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:DOUGLAS
Other - Middle Name:KEITH
Other - Last Name:BRADFORD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNA
Mailing Address - Street 1:856 BYERS RD
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30512-3977
Mailing Address - Country:US
Mailing Address - Phone:334-799-1549
Mailing Address - Fax:
Practice Address - Street 1:856 BYERS RD
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512-3977
Practice Address - Country:US
Practice Address - Phone:334-799-1549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-066257367500000X
FLAPRN9349539367500000X
GARN270343367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered