Provider Demographics
NPI:1871660555
Name:BRADLEY, JOHN C (CRNA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:CRNA
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 18139
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27619-8139
Mailing Address - Country:US
Mailing Address - Phone:636-549-2380
Mailing Address - Fax:314-569-5974
Practice Address - Street 1:9104 MARKET ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28411-7994
Practice Address - Country:US
Practice Address - Phone:301-694-3400
Practice Address - Fax:301-694-3620
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2011-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR118379367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKBC1CHOtherCAREFIRST BCBS
MDP00728709OtherMEDICARE RAILROAD (GRP PTAN CJ8689)
MDR118379OtherLICENSE
DCS417 0030OtherCAREFIRST BCBS
MD403621200Medicaid
MDP00745073OtherMEDICARE RAILROAD (GRP PTAN DD6120)
MDNNO4M380Medicare ID - Type Unspecified
MD403621200Medicaid