Healthcare Provider Details

I. General information

NPI: 1659935476
Provider Name (Legal Business Name): THOMAS A BRADLEY APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2019
Last Update Date: 02/08/2020
Certification Date: 02/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 WILSON FARM RD
GREENBRIER AR
72058
US

IV. Provider business mailing address

101 W MAIN ST
HARDY AR
72542-9566
US

V. Phone/Fax

Practice location:
  • Phone: 870-895-2015
  • Fax: 870-895-2164
Mailing address:
  • Phone:
  • Fax: 870-856-2133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA006073
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: