Provider Demographics
NPI:1942478656
Name:BRADWELL, ROSE CALI I (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ROSE
Middle Name:CALI
Last Name:BRADWELL
Suffix:I
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ROSE
Other - Middle Name:CALI
Other - Last Name:ST. JACQUES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1097 BIG TORCH ST
Mailing Address - Street 2:
Mailing Address - City:RIVIERA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-1140
Mailing Address - Country:US
Mailing Address - Phone:561-845-1669
Mailing Address - Fax:
Practice Address - Street 1:3800 S OCEAN DR STE 209
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33019-2915
Practice Address - Country:US
Practice Address - Phone:305-466-9988
Practice Address - Fax:305-466-9989
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-15
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102203363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHT448ZMedicaid