Healthcare Provider Details

I. General information

NPI: 1700259181
Provider Name (Legal Business Name): ELIZABETH ALEXANDRA BRADBURY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2015
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4140 JADE ST STE 100
CAPITOLA CA
95010-3940
US

IV. Provider business mailing address

PO BOX 31396
WALNUT CREEK CA
94598-8396
US

V. Phone/Fax

Practice location:
  • Phone: 831-475-4024
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number53014
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: