Provider Demographics
NPI:1689928665
Name:SPROSS, BRAD
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:
Last Name:SPROSS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 BOWEN ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-2013
Mailing Address - Country:US
Mailing Address - Phone:920-303-5006
Mailing Address - Fax:
Practice Address - Street 1:2101 BOWEN ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-2013
Practice Address - Country:US
Practice Address - Phone:920-303-5006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13159-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist