Provider Demographics
NPI:1265004774
Name:NELSON, BRADLEY ALLEN (PTA)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:ALLEN
Last Name:NELSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2506 COLORADO ST
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:KS
Mailing Address - Zip Code:67502-5144
Mailing Address - Country:US
Mailing Address - Phone:620-727-0365
Mailing Address - Fax:
Practice Address - Street 1:600 W BLANCHARD AVE
Practice Address - Street 2:
Practice Address - City:SOUTH HUTCHINSON
Practice Address - State:KS
Practice Address - Zip Code:67505-1526
Practice Address - Country:US
Practice Address - Phone:620-663-7175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-03780225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant