Provider Demographics
NPI:1629772231
Name:KLEINERT, BRADLEY DAVIS JACK (PA-C)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:DAVIS JACK
Last Name:KLEINERT
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 1:1591 NW 102ND WAY
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33071-3916
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8200 W SUNRISE BLVD BLDG C
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33322-5426
Practice Address - Country:US
Practice Address - Phone:954-370-8585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-28
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9117215363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical