Provider Demographics
NPI:1508822032
Name:KELLER, BRADLEY S (CRNA)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:S
Last Name:KELLER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7446 BRITISH RD
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-5511
Mailing Address - Country:US
Mailing Address - Phone:423-344-9826
Mailing Address - Fax:
Practice Address - Street 1:1801 GUNBARREL RD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-3130
Practice Address - Country:US
Practice Address - Phone:423-855-6861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000010562367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered