Provider Demographics
NPI:1205863750
Name:OTT, BRADLEY WILLIAM (CRNA)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:WILLIAM
Last Name:OTT
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E LIBERTY ST STE 800
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1428
Mailing Address - Country:US
Mailing Address - Phone:502-587-4404
Mailing Address - Fax:502-587-4156
Practice Address - Street 1:200 ABRAHAM FLEXNER WAY
Practice Address - Street 2:ANESTHESIA DEPARTMENT
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-2877
Practice Address - Country:US
Practice Address - Phone:502-587-4404
Practice Address - Fax:502-587-4156
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3004551367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200512440AMedicaid
KY74009945Medicaid
KY74009945Medicaid
KY0516858Medicare PIN