Provider Demographics
NPI:1093355497
Name:ILLESCAS, BRADLEY
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:
Last Name:ILLESCAS
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 1:12905 LAYHILL RD
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20906-3329
Mailing Address - Country:US
Mailing Address - Phone:240-855-4481
Mailing Address - Fax:
Practice Address - Street 1:12905 LAYHILL RD
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20906-3329
Practice Address - Country:US
Practice Address - Phone:240-855-4481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-14
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant