Provider Demographics
NPI:1902319635
Name:BRADBURY, PAUL RICHARD (PA-S)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:RICHARD
Last Name:BRADBURY
Suffix:
Gender:M
Credentials:PA-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 4TH ST NW
Mailing Address - Street 2:
Mailing Address - City:CHOTEAU
Mailing Address - State:MT
Mailing Address - Zip Code:59422-9123
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:915 4TH ST NW
Practice Address - Street 2:
Practice Address - City:CHOTEAU
Practice Address - State:MT
Practice Address - Zip Code:59422-9123
Practice Address - Country:US
Practice Address - Phone:865-386-3005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-16
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT62772363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant