Provider Demographics
NPI:1043598477
Name:BROWN, BRADLY KENNETH LEROY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BRADLY
Middle Name:KENNETH LEROY
Last Name:BROWN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2730 CHANNING WAY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-5049
Mailing Address - Country:US
Mailing Address - Phone:208-542-7100
Mailing Address - Fax:208-542-7150
Practice Address - Street 1:2730 CHANNING WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-5049
Practice Address - Country:US
Practice Address - Phone:208-542-7100
Practice Address - Fax:208-542-7150
Is Sole Proprietor?:No
Enumeration Date:2011-08-03
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA965207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine