Healthcare Provider Details

I. General information

NPI: 1023085255
Provider Name (Legal Business Name): WADE J BRAVO PA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1381 S PATRICK DRIVE 45TH MEDICAL GROUP
PATRICK AFB FL
32925
US

IV. Provider business mailing address

1381 S PATRICK DRIVE 45TH MEDICAL GROUP
PATRICK AFB FL
32925
US

V. Phone/Fax

Practice location:
  • Phone: 321-494-8159
  • Fax: 321-494-1378
Mailing address:
  • Phone: 321-494-8159
  • Fax: 321-494-1378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2830
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: