MEDICARE: BRAD JAMES GAUTNEY CPNP-PC

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	363LP0200X	Pediatric Nurse Practitioner	AP145468	TX
2	163W00000X	Registered Nurse	672090	TX
3	363L00000X	Nurse Practitioner	AP145468	TX

General Provider Information

NPI Number	:	1467074302
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRAD JAMES GAUTNEY CPNP-PC

Provider Business Mailing Address
First Line	:	1111 W AIRPORT FWY STE 143
Second Line	:
City	:	IRVING
State	:	TX
Zip	:	75062-6204
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1111 W AIRPORT FWY STE 143
Second Line	:
City	:	IRVING
State	:	TX
Zip	:	75062-6204
Country	:	US
Telephone Number	:	469-488-4500
Fax Number	:	469-488-4501

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

Provider Enumeration Date	:	05/14/2020
Last Update Date	:	01/08/2026

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