Provider Demographics
NPI:1699229112
Name:BRADLEY, BODEN (PA-C)
Entity Type:Individual
Prefix:
First Name:BODEN
Middle Name:
Last Name:BRADLEY
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 1:3005 DOUGLAS BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3885
Mailing Address - Country:US
Mailing Address - Phone:916-742-7718
Mailing Address - Fax:
Practice Address - Street 1:3005 DOUGLAS BLVD STE 105
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3885
Practice Address - Country:US
Practice Address - Phone:916-742-7718
Practice Address - Fax:510-350-9190
Is Sole Proprietor?:No
Enumeration Date:2016-08-12
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56390363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant