Provider Demographics
NPI:1235194648
Name:DIRKS, BRADLEY R (PAC)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:R
Last Name:DIRKS
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 1:1251 W CEDAR LOOP
Mailing Address - Street 2:
Mailing Address - City:CHEROKEE
Mailing Address - State:IA
Mailing Address - Zip Code:51012-1599
Mailing Address - Country:US
Mailing Address - Phone:712-225-2594
Mailing Address - Fax:712-225-1684
Practice Address - Street 1:1251 W CEDAR LOOP
Practice Address - Street 2:
Practice Address - City:CHEROKEE
Practice Address - State:IA
Practice Address - Zip Code:51012-1599
Practice Address - Country:US
Practice Address - Phone:712-225-2594
Practice Address - Fax:712-225-1684
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001213363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
R19878Medicare UPIN