Provider Demographics
NPI:1336141118
Name:ADAMS, BRADLEY E (PAC)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:E
Last Name:ADAMS
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 372
Mailing Address - Street 2:
Mailing Address - City:TYNDALL
Mailing Address - State:SD
Mailing Address - Zip Code:57066-0372
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2205 MAIN ST
Practice Address - Street 2:
Practice Address - City:TYNDALL
Practice Address - State:SD
Practice Address - Zip Code:57066-2324
Practice Address - Country:US
Practice Address - Phone:605-464-0545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1185363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE06154OtherBLUE CROSS BLUE SHIELD NE
NE06154OtherBLUE CROSS BLUE SHIELD NE
NEP25948Medicare UPIN
NEMA0632520OtherDEA #