Provider Demographics
NPI:1265993646
Name:SANDS, BRADLEY ALEN
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:ALEN
Last Name:SANDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 CORVETTE DR
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62056-1038
Mailing Address - Country:US
Mailing Address - Phone:217-324-3400
Mailing Address - Fax:
Practice Address - Street 1:1188 SOUTH STATE ROUTE 157
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025
Practice Address - Country:US
Practice Address - Phone:618-220-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-27
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209019065363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner