Provider Demographics
NPI:1407557861
Name:BRADLEY, RODRIQUES DEMARIO SANTIL (PA)
Entity Type:Individual
Prefix:
First Name:RODRIQUES
Middle Name:DEMARIO SANTIL
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:RODRIQUES
Other - Middle Name:DEMARIO SANTIL
Other - Last Name:BRADLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:1811 N WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-3403
Mailing Address - Country:US
Mailing Address - Phone:704-616-7141
Mailing Address - Fax:
Practice Address - Street 1:1811 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-3403
Practice Address - Country:US
Practice Address - Phone:323-533-5626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62466363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant