Provider Demographics
NPI:1467074302
Name:GAUTNEY, BRAD JAMES (CPNP-PC)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:JAMES
Last Name:GAUTNEY
Suffix:
Gender:M
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3975 HIGHGROVE DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75220-3753
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1011 W GROVE ST STE 120
Practice Address - Street 2:
Practice Address - City:KAUFMAN
Practice Address - State:TX
Practice Address - Zip Code:75142-1883
Practice Address - Country:US
Practice Address - Phone:972-962-1062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-14
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP145468363LP0200X
TX672090163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse