Provider Demographics
NPI:1790225076
Name:BROWN, BRADLEY (ATC)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:BROWN
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MEMORIAL STADIUM DR
Mailing Address - Street 2:ATHLETIC MEDICINE DEPT.
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68588-0031
Mailing Address - Country:US
Mailing Address - Phone:402-472-4382
Mailing Address - Fax:
Practice Address - Street 1:1 MEMORIAL STADIUM DR
Practice Address - Street 2:ATHLETIC MEDICINE DEPT.
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68588-0031
Practice Address - Country:US
Practice Address - Phone:402-472-4382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE74405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional