Provider Demographics
NPI:1992027940
Name:BRADLEY, NICOLAS (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLAS
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 W PARKS HWY STE 101
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-6939
Mailing Address - Country:US
Mailing Address - Phone:073-577-7819
Mailing Address - Fax:907-745-6573
Practice Address - Street 1:1301 W PARKS HWY STE 101
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6939
Practice Address - Country:US
Practice Address - Phone:073-577-7819
Practice Address - Fax:907-745-6573
Is Sole Proprietor?:No
Enumeration Date:2010-02-18
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKPADA1173363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant