Provider Demographics
NPI:1508574310
Name:BRADLEY, SAVANNAH (PA)
Entity Type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 RESEARCH RD
Mailing Address - Street 2:
Mailing Address - City:RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:11961-2701
Mailing Address - Country:US
Mailing Address - Phone:631-751-3000
Mailing Address - Fax:
Practice Address - Street 1:12 E 86TH ST OFC 4C
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-0517
Practice Address - Country:US
Practice Address - Phone:631-751-3000
Practice Address - Fax:631-751-0506
Is Sole Proprietor?:No
Enumeration Date:2022-11-10
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029281363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant