Provider Demographics
NPI:1164253209
Name:BRADFORD, MIA MONAE
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:MONAE
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 JASMINE AVE
Mailing Address - Street 2:
Mailing Address - City:ATWATER
Mailing Address - State:CA
Mailing Address - Zip Code:95301-4865
Mailing Address - Country:US
Mailing Address - Phone:209-424-8425
Mailing Address - Fax:
Practice Address - Street 1:6 JASMINE AVE
Practice Address - Street 2:
Practice Address - City:ATWATER
Practice Address - State:CA
Practice Address - Zip Code:95301-4865
Practice Address - Country:US
Practice Address - Phone:209-424-8425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-10
Last Update Date:2024-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA011567612472R0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2472R0900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherRenal Dialysis