Provider Demographics
NPI:1104180975
Name:STEPHENSON, BRADLEY DANIEL (PA)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:DANIEL
Last Name:STEPHENSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8450 NORTHWEST BLVD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46278-1381
Mailing Address - Country:US
Mailing Address - Phone:317-802-2000
Mailing Address - Fax:317-802-2170
Practice Address - Street 1:8402 HARCOURT RD STE 125
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2094
Practice Address - Country:US
Practice Address - Phone:317-802-2000
Practice Address - Fax:317-802-3972
Is Sole Proprietor?:No
Enumeration Date:2012-06-27
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001408A363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical