Provider Demographics
NPI:1013990209
Name:FREY, BRADLEY DUANE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:DUANE
Last Name:FREY
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 1:4 FULLER ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA BAY
Mailing Address - State:NY
Mailing Address - Zip Code:13607-1391
Mailing Address - Country:US
Mailing Address - Phone:315-482-1277
Mailing Address - Fax:315-482-5553
Practice Address - Street 1:4 FULLER ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA BAY
Practice Address - State:NY
Practice Address - Zip Code:13607-1391
Practice Address - Country:US
Practice Address - Phone:315-482-1203
Practice Address - Fax:315-482-4911
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009322363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYVAD000Medicare UPIN