Healthcare Provider Details

I. General information

NPI: 1093864829
Provider Name (Legal Business Name): BRADLEY DEAN SUMMERS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 07/08/2021
Certification Date: 07/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 N CHINA LAKE BLVD RIDGECREST REGIONAL HOSPITAL
RIDGECREST CA
93555-3131
US

IV. Provider business mailing address

FILE 50670
LOS ANGELES CA
90074-0670
US

V. Phone/Fax

Practice location:
  • Phone: 760-499-3800
  • Fax:
Mailing address:
  • Phone: 888-227-3312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA17047
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: