Provider Demographics
NPI:1770556441
Name:BRADLEY, JAMES J (CRNA)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:J
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33990 CANYON MILL RD
Mailing Address - Street 2:
Mailing Address - City:RONAN
Mailing Address - State:MT
Mailing Address - Zip Code:59864-9160
Mailing Address - Country:US
Mailing Address - Phone:406-676-0216
Mailing Address - Fax:
Practice Address - Street 1:5516 MOUNTAIN GARLAND DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80923
Practice Address - Country:US
Practice Address - Phone:830-776-6495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-10
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT38977367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO918517046Medicaid
OTH000Medicare UPIN
MO918517046Medicaid
430049689Medicare PIN