Provider Demographics
NPI:1114347937
Name:IBRADO, ROY GRANT
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:GRANT
Last Name:IBRADO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ROY
Other - Middle Name:
Other - Last Name:CZARNECKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3925 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53207-4301
Mailing Address - Country:US
Mailing Address - Phone:414-617-7053
Mailing Address - Fax:
Practice Address - Street 1:3124 S TAYLOR AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53207-2724
Practice Address - Country:US
Practice Address - Phone:414-617-7053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-19
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI195948-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse