Provider Demographics
NPI:1184130692
Name:DILLON, BRADLEY (NP)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:DILLON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 CAITLYN DR
Mailing Address - Street 2:
Mailing Address - City:SALTILLO
Mailing Address - State:MS
Mailing Address - Zip Code:38866-8103
Mailing Address - Country:US
Mailing Address - Phone:662-574-7595
Mailing Address - Fax:
Practice Address - Street 1:2601 GETWELL RD STE 4
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-6762
Practice Address - Country:US
Practice Address - Phone:662-643-4533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-19
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902456363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01155847Medicaid