Provider Demographics
NPI:1790103976
Name:PETTY, BRADLEY JAMES (MD)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:JAMES
Last Name:PETTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:550 GAGE BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-9532
Mailing Address - Country:US
Mailing Address - Phone:509-942-3627
Mailing Address - Fax:509-627-2983
Practice Address - Street 1:780 SWIFT BLVD STE 301
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3524
Practice Address - Country:US
Practice Address - Phone:509-942-3178
Practice Address - Fax:509-946-1735
Is Sole Proprietor?:No
Enumeration Date:2014-04-03
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
390200000X
WAMD60907536207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program