Provider Demographics
NPI:1114014180
Name:BLISS, BRADLEY (PAC)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:BLISS
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14477 CABERFAE HWY
Mailing Address - Street 2:
Mailing Address - City:WELLSTON
Mailing Address - State:MI
Mailing Address - Zip Code:49689-9315
Mailing Address - Country:US
Mailing Address - Phone:231-848-4777
Mailing Address - Fax:
Practice Address - Street 1:14477 CABERFAE HWY
Practice Address - Street 2:
Practice Address - City:WELLSTON
Practice Address - State:MI
Practice Address - Zip Code:49689-9315
Practice Address - Country:US
Practice Address - Phone:231-848-4777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007455363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601001299OtherMICHIGAN PAC LICENSE
MI5601001299OtherMICHIGAN PAC LICENSE
MIMB0528680OtherDEA NUMBER