Provider Demographics
NPI:1568885077
Name:LASLEY, BRADLEY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:
Last Name:LASLEY
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 1:2005 MIZELL AVE STE 2100
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-4126
Mailing Address - Country:US
Mailing Address - Phone:407-599-6460
Mailing Address - Fax:407-599-6461
Practice Address - Street 1:2005 MIZELL AVE STE 2100
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-4126
Practice Address - Country:US
Practice Address - Phone:407-599-6460
Practice Address - Fax:407-599-6461
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-04
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5606363A00000X
FLPA9111766363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant