Provider Demographics
NPI:1285639724
Name:AFFATATO-BRADLEY, LISA (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:AFFATATO-BRADLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 HUNTINGDON PIKE STE C
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:PA
Mailing Address - Zip Code:19046-4431
Mailing Address - Country:US
Mailing Address - Phone:215-780-2000
Mailing Address - Fax:215-780-2007
Practice Address - Street 1:400 HUNTINGDON PIKE STE C
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:PA
Practice Address - Zip Code:19046-4431
Practice Address - Country:US
Practice Address - Phone:215-780-2000
Practice Address - Fax:215-780-2007
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD056730L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000070Medicare PIN
PAG61653Medicare UPIN