Provider Demographics
NPI:1669877387
Name:HENNINGSGAARD, BRADLEY (PA-C)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:HENNINGSGAARD
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 1:5345 SILVER MOON LN
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27606-4534
Mailing Address - Country:US
Mailing Address - Phone:512-426-1814
Mailing Address - Fax:
Practice Address - Street 1:2301 ERWIN RD DEPARTMENT OF RADIOLOGY
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27710-1645
Practice Address - Country:US
Practice Address - Phone:919-684-7284
Practice Address - Fax:919-613-2680
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-23
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-06919363A00000X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0110004775OtherSTATE LICENSE