Provider Demographics
NPI:1639258668
Name:BANGS, BRADLEY DAVID (PT)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:DAVID
Last Name:BANGS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1423 7TH ST
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:NE
Mailing Address - Zip Code:68818-1141
Mailing Address - Country:US
Mailing Address - Phone:402-694-8254
Mailing Address - Fax:
Practice Address - Street 1:1423 7TH ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:NE
Practice Address - Zip Code:68818-1141
Practice Address - Country:US
Practice Address - Phone:402-694-8254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT58715342401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP6311Medicaid