Provider Demographics
NPI:1881791986
Name:COLLINS, BRADLEY DONALD (PA-C)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:DONALD
Last Name:COLLINS
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 1:558 E ROSEWOOD CT
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-2827
Mailing Address - Country:US
Mailing Address - Phone:909-988-1145
Mailing Address - Fax:
Practice Address - Street 1:345 TERRACINA BLVD
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4829
Practice Address - Country:US
Practice Address - Phone:909-793-1399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15218207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPA15218Medicare ID - Type Unspecified