Provider Demographics
NPI:1295215788
Name:YOUNGERS, BRADLEY (PA)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:YOUNGERS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7808 LAKESIDE BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-3369
Mailing Address - Country:US
Mailing Address - Phone:515-779-1717
Mailing Address - Fax:
Practice Address - Street 1:6101 PINE RIDGE RD
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34119
Practice Address - Country:US
Practice Address - Phone:239-348-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-15
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111455363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty