Provider Demographics
NPI:1043671647
Name:BRADBERRY, DANIEL C
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:C
Last Name:BRADBERRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 29TH AVE N
Mailing Address - Street 2:SUITE 202
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1401
Mailing Address - Country:US
Mailing Address - Phone:615-327-7870
Mailing Address - Fax:615-921-5506
Practice Address - Street 1:110 29TH AVE N
Practice Address - Street 2:SUITE 202
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-1401
Practice Address - Country:US
Practice Address - Phone:615-327-7870
Practice Address - Fax:615-921-5506
Is Sole Proprietor?:No
Enumeration Date:2016-03-10
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN178536163W00000X
TN21246367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ022209Medicaid
TN103I437957Medicare PIN