Healthcare Provider Details

I. General information

NPI: 1053250159
Provider Name (Legal Business Name): BRADLEY RANDALL WINTERS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2026
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 CHILD ST DEPT 5000
JACKSONVILLE FL
32214-5000
US

IV. Provider business mailing address

644 MARYSVILLE WAY
RICHLAND WA
99352-7880
US

V. Phone/Fax

Practice location:
  • Phone: 904-542-7300
  • Fax:
Mailing address:
  • Phone: 843-833-2276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: