Provider Demographics
NPI:1972501849
Name:NACE, BRADLEY A
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:A
Last Name:NACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:BRADLEY
Other - Middle Name:A
Other - Last Name:NACE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:240 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WOLFEBORO
Mailing Address - State:NH
Mailing Address - Zip Code:03894-4455
Mailing Address - Country:US
Mailing Address - Phone:603-569-7690
Mailing Address - Fax:603-569-7664
Practice Address - Street 1:240 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WOLFEBORO
Practice Address - State:NH
Practice Address - Zip Code:03894-4455
Practice Address - Country:US
Practice Address - Phone:603-569-7690
Practice Address - Fax:603-569-7664
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA003465L363A00000X
COPA.0003736363A00000X
NH2149363AS0400X
IDPA-2307363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO59036371Medicaid
CO59036371Medicaid
PA228009Medicare PIN
CO299677YLA0Medicare PIN