Provider Demographics
NPI:1790931210
Name:RICHARDS, BRADLEY D (PA-C)
Entity type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:D
Last Name:RICHARDS
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 1:3584 W 9000 S STE 305
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-4775
Mailing Address - Country:US
Mailing Address - Phone:801-992-1233
Mailing Address - Fax:385-301-5544
Practice Address - Street 1:3584 W 9000 S STE 305
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-4775
Practice Address - Country:US
Practice Address - Phone:801-992-1233
Practice Address - Fax:385-301-5544
Is Sole Proprietor?:No
Enumeration Date:2008-08-15
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4827363A00000X
UT5000567-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ614642Medicaid
AZ614642Medicaid