Provider Demographics
NPI:1881610616
Name:BRADLEY, BRIAN M (CRNA)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:M
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 W PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:ANACONDA
Mailing Address - State:MT
Mailing Address - Zip Code:59711-1999
Mailing Address - Country:US
Mailing Address - Phone:406-563-8528
Mailing Address - Fax:406-556-3086
Practice Address - Street 1:401 W PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:ANACONDA
Practice Address - State:MT
Practice Address - Zip Code:59711
Practice Address - Country:US
Practice Address - Phone:406-563-8528
Practice Address - Fax:406-556-3086
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT27323208VP0014X
MTRN27323367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1881610616Medicaid
MT0437852Medicaid
WA9639683Medicaid
MN139708700Medicaid