Provider Demographics
NPI:1831831510
Name:BRADFORD, COURTNEY (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:
Other - Last Name:KISTLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AGACNP-BC
Mailing Address - Street 1:6343 E MAIN ST STE 12
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-8955
Mailing Address - Country:US
Mailing Address - Phone:480-835-6100
Mailing Address - Fax:
Practice Address - Street 1:6750 E BAYWOOD AVE STE 301
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-1749
Practice Address - Country:US
Practice Address - Phone:480-835-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-12
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ271346207RI0011X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology