Provider Demographics
NPI:1891708616
Name:NIELSON, BRADLEY KYLE (OD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:KYLE
Last Name:NIELSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 N 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-1806
Mailing Address - Country:US
Mailing Address - Phone:509-529-7371
Mailing Address - Fax:
Practice Address - Street 1:208 N 2ND AVE
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-1806
Practice Address - Country:US
Practice Address - Phone:509-529-7371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3519WA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2130268WAMedicaid
WA2017328Medicaid
WA2017328Medicaid
WAG8909396Medicare PIN
WAU76711Medicare UPIN