Provider Demographics
NPI:1689994147
Name:SPETA, BRADLEY ALAN (ANP)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:ALAN
Last Name:SPETA
Suffix:
Gender:M
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 MARTIN ST
Mailing Address - Street 2:
Mailing Address - City:WELLSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14895-1057
Mailing Address - Country:US
Mailing Address - Phone:585-593-7460
Mailing Address - Fax:585-593-7474
Practice Address - Street 1:12 MARTIN ST
Practice Address - Street 2:
Practice Address - City:WELLSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14895-1057
Practice Address - Country:US
Practice Address - Phone:585-593-7460
Practice Address - Fax:585-593-7474
Is Sole Proprietor?:No
Enumeration Date:2010-06-08
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF305382-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health