Provider Demographics
NPI:1548200843
Name:BRADLEY, LAURA E (PAC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:E
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 SPRING VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25704-9300
Mailing Address - Country:US
Mailing Address - Phone:606-922-2316
Mailing Address - Fax:
Practice Address - Street 1:1540 SPRING VALLEY DR
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25704-9300
Practice Address - Country:US
Practice Address - Phone:606-922-2316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA456207Q00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95001376Medicaid
KY0351450Medicare ID - Type Unspecified
KY0632948Medicare ID - Type Unspecified
KY0586623Medicare ID - Type Unspecified
KY0307652Medicare ID - Type Unspecified
KY3400334Medicare ID - Type Unspecified
P00208787Medicare ID - Type UnspecifiedRAIL ROAD MEDICARE
KY95001376Medicaid
KY0264258Medicare ID - Type Unspecified