Provider Demographics
NPI:1932199239
Name:GRIFFIN, BRADLEY (CRNA)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:GRIFFIN
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 1:12902 USF MAGNOLIA DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-9416
Mailing Address - Country:US
Mailing Address - Phone:813-745-8486
Mailing Address - Fax:813-745-3064
Practice Address - Street 1:12902 USF MAGNOLIA DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-9416
Practice Address - Country:US
Practice Address - Phone:813-745-8486
Practice Address - Fax:813-745-3064
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH289551367500000X
FLARNP9274530367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000173500Medicaid
OH2564069Medicaid
OHGR8235381Medicare ID - Type Unspecified
FLAL667ZMedicare PIN