Healthcare Provider Details

I. General information

NPI: 1679113989
Provider Name (Legal Business Name): BRADLEY MICHAEL STIEFEL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2020
Last Update Date: 07/27/2020
Certification Date: 07/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6677 W THUNDERBIRD RD STE I164
GLENDALE AZ
85306-3762
US

IV. Provider business mailing address

22539 CASCADE DR
CANYON LAKE CA
92587-7942
US

V. Phone/Fax

Practice location:
  • Phone: 623-878-2100
  • Fax: 623-776-9419
Mailing address:
  • Phone: 951-566-7854
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7867
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: