Provider Demographics
NPI:1205103389
Name:HENINGER, BRADLEY JAMES (PA-C)
Entity type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:JAMES
Last Name:HENINGER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-452-3111
Mailing Address - Fax:208-452-3666
Practice Address - Street 1:910 NW 16TH STREET
Practice Address - Street 2:STE 205
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619
Practice Address - Country:US
Practice Address - Phone:208-452-3111
Practice Address - Fax:208-452-3666
Is Sole Proprietor?:No
Enumeration Date:2011-11-17
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR363AM0700X
IDPA-1026363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical