Healthcare Provider Details

I. General information

NPI: 1043598477
Provider Name (Legal Business Name): BRADLY KENNETH LEROY BROWN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2011
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 POLE LINE RD W
TWIN FALLS ID
83301-5800
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-814-1600
  • Fax: 208-814-1910
Mailing address:
  • Phone: 208-381-8866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberPA60639841
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberPA-965
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: