Provider Demographics
NPI:1649375940
Name:BRADLEY, WILLIAM (FNP)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:420 SEMO DR
Mailing Address - Street 2:P O BOX 400
Mailing Address - City:NEW MADRID
Mailing Address - State:MO
Mailing Address - Zip Code:63869-1734
Mailing Address - Country:US
Mailing Address - Phone:573-748-2404
Mailing Address - Fax:573-748-8929
Practice Address - Street 1:200 SOUTHLAND DR
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-4403
Practice Address - Country:US
Practice Address - Phone:573-427-1770
Practice Address - Fax:573-472-4050
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO131573363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO427752506Medicaid
MO427752506Medicaid
R08689Medicare UPIN