Provider Demographics
NPI:1619396249
Name:DALLING, BRADLEY SCOTT (CRNA)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:SCOTT
Last Name:DALLING
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 1:1828 S MILLENIUM WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-5036
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 EAST BLVD
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2483
Practice Address - Country:US
Practice Address - Phone:801-822-2011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-10
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID101872367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered