Provider Demographics
NPI:1710679808
Name:JEFFERS, BRADLEY AARON (RN)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:AARON
Last Name:JEFFERS
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4320 HAZELWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37664-4963
Mailing Address - Country:US
Mailing Address - Phone:423-292-0797
Mailing Address - Fax:
Practice Address - Street 1:130 W RAVINE RD
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3837
Practice Address - Country:US
Practice Address - Phone:423-224-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-25
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000230362163W00000X
TN34801367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse