Provider Demographics
NPI:1750627386
Name:BRADWELL, ONIQUA D (PA-C)
Entity type:Individual
Prefix:MISS
First Name:ONIQUA
Middle Name:D
Last Name:BRADWELL
Suffix:
Gender:F
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 1:5000 COX RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9263
Mailing Address - Country:US
Mailing Address - Phone:049-685-7008
Mailing Address - Fax:
Practice Address - Street 1:6201 ANNAPOLIS RD
Practice Address - Street 2:
Practice Address - City:LANDOVER HILLS
Practice Address - State:MD
Practice Address - Zip Code:20784-1307
Practice Address - Country:US
Practice Address - Phone:301-276-3377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-01
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA030827363AM0700X
MDC04230363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical