Provider Demographics
NPI:1023085255
Name:BRAVO, WADE J (PA)
Entity type:Individual
Prefix:
First Name:WADE
Middle Name:J
Last Name:BRAVO
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 1:1381 S PATRICK DRIVE
Mailing Address - Street 2:45TH MEDICAL GROUP
Mailing Address - City:PATRICK AFB
Mailing Address - State:FL
Mailing Address - Zip Code:32925
Mailing Address - Country:US
Mailing Address - Phone:321-494-8159
Mailing Address - Fax:321-494-1378
Practice Address - Street 1:1381 S PATRICK DRIVE
Practice Address - Street 2:45TH MEDICAL GROUP
Practice Address - City:PATRICK AFB
Practice Address - State:FL
Practice Address - Zip Code:32925
Practice Address - Country:US
Practice Address - Phone:321-494-8159
Practice Address - Fax:321-494-1378
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2830363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN