Provider Demographics
NPI:1831473198
Name:BRADBERRY, CALI J (PA-C)
Entity Type:Individual
Prefix:
First Name:CALI
Middle Name:J
Last Name:BRADBERRY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5985 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-3039
Mailing Address - Country:US
Mailing Address - Phone:208-853-0071
Mailing Address - Fax:208-853-9422
Practice Address - Street 1:4750 N FIVE MILE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-2715
Practice Address - Country:US
Practice Address - Phone:208-375-0500
Practice Address - Fax:208-375-4310
Is Sole Proprietor?:No
Enumeration Date:2011-10-05
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-9372084P0800X, 363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant