Provider Demographics
NPI:1295761153
Name:HALL, BRADLEY GERALD (PA-C)
Entity type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:GERALD
Last Name:HALL
Suffix:
Gender:M
Credentials:PA-C
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 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:702-579-3203
Mailing Address - Fax:
Practice Address - Street 1:14973 W BELL RD STE 100
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-3878
Practice Address - Country:US
Practice Address - Phone:623-815-2900
Practice Address - Fax:623-583-1319
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3037363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ85516OtherMEDICARE PIN #
AZ85516OtherMEDICARE PIN #
AZQ29049Medicare UPIN