Provider Demographics
NPI:1053075077
Name:BRADFORD, TY DAVID (PA-C)
Entity Type:Individual
Prefix:
First Name:TY
Middle Name:DAVID
Last Name:BRADFORD
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 1:1331 ORCHARD HEIGHTS RD NW APT 3069
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-2573
Mailing Address - Country:US
Mailing Address - Phone:530-598-0525
Mailing Address - Fax:
Practice Address - Street 1:863 LIBERTY ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-2451
Practice Address - Country:US
Practice Address - Phone:877-522-1275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-26
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA60273363A00000X
ORPA207912363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant