Provider Demographics
NPI:1902557226
Name:BRADBURY, ALEC
Entity Type:Individual
Prefix:
First Name:ALEC
Middle Name:
Last Name:BRADBURY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12710 BROOKPARK RD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94619-3137
Mailing Address - Country:US
Mailing Address - Phone:510-289-0658
Mailing Address - Fax:
Practice Address - Street 1:16 RITTER ST
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-3323
Practice Address - Country:US
Practice Address - Phone:415-457-8182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-18
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95019763363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily