Provider Demographics
NPI:1356379192
Name:BRADLEY-GUIDRY, CAROLYN DENESE (MS, PAC)
Entity type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:DENESE
Last Name:BRADLEY-GUIDRY
Suffix:
Gender:F
Credentials:MS, PAC
Other - Prefix:MRS
Other - First Name:CAROLYN
Other - Middle Name:DENESE
Other - Last Name:BRADLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:PO BOX 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-5347
Mailing Address - Country:US
Mailing Address - Phone:214-645-6000
Mailing Address - Fax:214-645-2762
Practice Address - Street 1:5323 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-7208
Practice Address - Country:US
Practice Address - Phone:214-645-8000
Practice Address - Fax:214-645-7269
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02262363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXS76608Medicare UPIN