Healthcare Provider Details

I. General information

NPI: 1578126561
Provider Name (Legal Business Name): BRADLEY W WINE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2019
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 MEALS AVE
VALDEZ AK
99686-0046
US

IV. Provider business mailing address

6615 HILLTOP LN SW
LAKEWOOD WA
98499-1426
US

V. Phone/Fax

Practice location:
  • Phone: 907-835-2249
  • Fax:
Mailing address:
  • Phone: 316-516-6170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD61653822
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number913315
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD.MD61653822
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: