Provider Demographics
NPI:1477597524
Name:HARTWIG, BRAD LYN (PA-C)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:LYN
Last Name:HARTWIG
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 1:1394 KIWANIS DR APT B302
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-6940
Mailing Address - Country:US
Mailing Address - Phone:815-821-4777
Mailing Address - Fax:
Practice Address - Street 1:11475 N 2ND ST
Practice Address - Street 2:
Practice Address - City:MACHESNEY PARK
Practice Address - State:IL
Practice Address - Zip Code:61115-1285
Practice Address - Country:US
Practice Address - Phone:815-654-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1167363A00000X
IL085-002982363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42988500Medicaid
WI42988500Medicaid
P01217Medicare UPIN