Provider Demographics
NPI:1720004740
Name:BRADFORD, JOHN EDWARD (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:EDWARD
Last Name:BRADFORD
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:PO BOX 58
Mailing Address - Street 2:
Mailing Address - City:YELLOWSTONE NATIONAL PARK
Mailing Address - State:WY
Mailing Address - Zip Code:82190-0058
Mailing Address - Country:US
Mailing Address - Phone:307-344-7965
Mailing Address - Fax:
Practice Address - Street 1:701 TUDOR DR
Practice Address - Street 2:STE 110
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503
Practice Address - Country:US
Practice Address - Phone:907-685-1420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT25769363A00000X
AKPADA1193363A00000X
WYPA732363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant