Provider Demographics
NPI:1336110865
Name:RICHARDSON, BRADLEY (CRNA)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4602 CR 673 # 7577
Mailing Address - Street 2:
Mailing Address - City:BUSHNELL
Mailing Address - State:FL
Mailing Address - Zip Code:33513-8358
Mailing Address - Country:US
Mailing Address - Phone:719-231-1238
Mailing Address - Fax:
Practice Address - Street 1:300 PINELLAS ST
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-3892
Practice Address - Country:US
Practice Address - Phone:727-543-4850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN168679163W00000X
TN13924367500000X
NM55704367500000X
FL11004008367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse