Provider Demographics
NPI:1730369364
Name:BRADWAY, KATHLEEN E
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:E
Last Name:BRADWAY
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 1:84 PERKINS DR
Mailing Address - Street 2:
Mailing Address - City:HUDSON FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12839-2646
Mailing Address - Country:US
Mailing Address - Phone:518-480-3350
Mailing Address - Fax:
Practice Address - Street 1:1262 DIX AVE
Practice Address - Street 2:
Practice Address - City:HUDSON FALLS
Practice Address - State:NY
Practice Address - Zip Code:12839-9618
Practice Address - Country:US
Practice Address - Phone:518-747-0292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-12
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049170183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY049170Medicaid