Provider Demographics
NPI:1134222011
Name:BRADLEY, STEPHEN (PA)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:BRADLEY
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:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:TOPPENISH
Mailing Address - State:WA
Mailing Address - Zip Code:98948-0190
Mailing Address - Country:US
Mailing Address - Phone:509-865-6175
Mailing Address - Fax:
Practice Address - Street 1:740 MEMORIAL ST
Practice Address - Street 2:
Practice Address - City:PROSSER
Practice Address - State:WA
Practice Address - Zip Code:99350-1525
Practice Address - Country:US
Practice Address - Phone:509-786-1931
Practice Address - Fax:509-786-1997
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10000296363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA142805OtherL & I
WA4750BROtherREGENCE
WA8296097Medicaid
1306897681OtherNPI PROSSER MEMORIAL
6972OtherGROUP HEALTH
WA8296097OtherCHPW
WA142805OtherL & I
WA8296097Medicaid