Provider Demographics
NPI:1164996245
Name:BAILEY, BRADLEY (PA-C)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:BAILEY
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 1:13109 WONDERLAND WAY APT 4
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20874-2399
Mailing Address - Country:US
Mailing Address - Phone:410-474-8877
Mailing Address - Fax:
Practice Address - Street 1:19851 OBSERVATION DR STE 250
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20876-4151
Practice Address - Country:US
Practice Address - Phone:301-972-0400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-11
Last Update Date:2020-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MDC0007464363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty