Provider Demographics
NPI:1548546435
Name:BRADLEY, BENJAMIN (PA-C)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:BRADLEY
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 1:305 EAST CENTER AVE.
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-6331
Mailing Address - Country:US
Mailing Address - Phone:559-737-4700
Mailing Address - Fax:559-737-4782
Practice Address - Street 1:12586 AVENUE 408
Practice Address - Street 2:
Practice Address - City:CUTLER/OROSI
Practice Address - State:CA
Practice Address - Zip Code:93647-9454
Practice Address - Country:US
Practice Address - Phone:559-528-2804
Practice Address - Fax:559-528-7623
Is Sole Proprietor?:No
Enumeration Date:2011-10-24
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21965363A00000X
CA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA21965OtherLICENSE