Provider Demographics
NPI:1467544122
Name:BRADFORD, AMANDA BROOKE (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:BROOKE
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HOSPITAL PLZ
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-3602
Mailing Address - Country:US
Mailing Address - Phone:203-276-7022
Mailing Address - Fax:203-276-5560
Practice Address - Street 1:1 HOSPITAL PLZ
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-3602
Practice Address - Country:US
Practice Address - Phone:203-276-7022
Practice Address - Fax:203-276-5560
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1790363A00000X
CT5043363A00000X
NY016534-1363A00000X
MAAP2224363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
14036666OtherCAQH