Provider Demographics
NPI:1225480551
Name:BRADLEY, KATHLEEN QUINTANA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:QUINTANA
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:MARIE
Other - Last Name:QUINTANA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1523 ELIZABETH AVE.
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204
Mailing Address - Country:US
Mailing Address - Phone:704-910-1402
Mailing Address - Fax:704-910-1506
Practice Address - Street 1:1523 ELIZABETH AVE.
Practice Address - Street 2:SUITE 200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204
Practice Address - Country:US
Practice Address - Phone:704-910-1402
Practice Address - Fax:704-910-1506
Is Sole Proprietor?:No
Enumeration Date:2016-07-11
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-06215363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant