Provider Demographics
NPI:1861695512
Name:BRADLEY, TABETHA HALE (MD)
Entity type:Individual
Prefix:
First Name:TABETHA
Middle Name:HALE
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TABETHA
Other - Middle Name:MARIE
Other - Last Name:HALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:503 E HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHELAN
Mailing Address - State:WA
Mailing Address - Zip Code:98816-8631
Mailing Address - Country:US
Mailing Address - Phone:509-682-8517
Mailing Address - Fax:509-682-9614
Practice Address - Street 1:503 E HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:CHELAN
Practice Address - State:WA
Practice Address - Zip Code:98816-8631
Practice Address - Country:US
Practice Address - Phone:509-682-8517
Practice Address - Fax:509-682-9614
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60274491208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1020730Medicaid