Provider Demographics
NPI:1245430602
Name:LORD, BRADLEY WADE (CRNA)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:WADE
Last Name:LORD
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
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Mailing Address - Street 1:7930 SW 84TH WAY
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-6129
Mailing Address - Country:US
Mailing Address - Phone:352-376-1921
Mailing Address - Fax:352-372-6956
Practice Address - Street 1:1500 SW 1ST AVE
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-6504
Practice Address - Country:US
Practice Address - Phone:352-237-2400
Practice Address - Fax:352-237-9808
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2007-07-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FL9189417367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered