Provider Demographics
NPI:1467591883
Name:KRALL, BRADLEY MARK (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:MARK
Last Name:KRALL
Suffix:
Gender:M
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 1:433 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362
Mailing Address - Country:US
Mailing Address - Phone:360-452-3373
Mailing Address - Fax:360-565-7635
Practice Address - Street 1:433 E 8TH ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362
Practice Address - Country:US
Practice Address - Phone:360-452-3373
Practice Address - Fax:360-565-7635
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004150363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7084486Medicaid
WA8EZ31SMedicare ID - Type Unspecified
WA7084486Medicaid