Provider Demographics
NPI:1932126976
Name:GALE, BRADFORD A (PA)
Entity Type:Individual
Prefix:
First Name:BRADFORD
Middle Name:A
Last Name:GALE
Suffix:
Gender:M
Credentials:PA
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 413033
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84141-3033
Mailing Address - Country:US
Mailing Address - Phone:801-213-3900
Mailing Address - Fax:801-587-6459
Practice Address - Street 1:100 MARIO CAPECCHI DRIVE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1103
Practice Address - Country:US
Practice Address - Phone:801-662-5400
Practice Address - Fax:801-587-6459
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT199792-1206363A00000X
UT199792-1205363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT97009604OtherPALMETTO
UT19979210200001OtherBCBS OF UTAH
UT97009604OtherPALMETTO
UTU000072425Medicare PIN
UT19979210200001OtherBCBS OF UTAH