MEDICARE: MR. BRADLEY ILLESCAS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant

General Provider Information

NPI Number	:	1093355497
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRADLEY ILLESCAS

Provider Business Mailing Address
First Line	:	12905 LAYHILL RD
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20906-3329
Country	:	US
Telephone Number	:	240-855-4481
Fax Number	:

Provider Business Practice Location Address
First Line	:	12905 LAYHILL RD
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20906-3329
Country	:	US
Telephone Number	:	240-855-4481
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/14/2020
Last Update Date	:	01/14/2020

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Directions to “ MR. BRADLEY ILLESCAS ” Practice Location

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