Provider Demographics
NPI:1780647545
Name:BONNELL-BRADLEY, OMEGA M (PA)
Entity Type:Individual
Prefix:
First Name:OMEGA
Middle Name:M
Last Name:BONNELL-BRADLEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 CANAL ST
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-6701
Mailing Address - Country:US
Mailing Address - Phone:781-338-0500
Mailing Address - Fax:
Practice Address - Street 1:230 WORCESTER ST
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481-5420
Practice Address - Country:US
Practice Address - Phone:781-431-5200
Practice Address - Fax:781-431-5298
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA382363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAP0374Medicare ID - Type Unspecified
MAS40331Medicare UPIN