Provider Demographics
NPI:1730518788
Name:BRADLEY, BENJAMIN (CNP)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447-4726
Mailing Address - Country:US
Mailing Address - Phone:918-756-3114
Mailing Address - Fax:877-403-5739
Practice Address - Street 1:1020 E 8TH ST
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-4726
Practice Address - Country:US
Practice Address - Phone:918-756-3114
Practice Address - Fax:877-403-5739
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-09
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK67001363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily