Healthcare Provider Details

I. General information

NPI: 1558762062
Provider Name (Legal Business Name): BRADLEY ELIAS SNYDER NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2014
Last Update Date: 03/04/2023
Certification Date: 02/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 W LOMBARD ST
BALTIMORE MD
21201-1512
US

IV. Provider business mailing address

3512 POOLE ST
BALTIMORE MD
21211-2327
US

V. Phone/Fax

Practice location:
  • Phone: 443-529-2745
  • Fax:
Mailing address:
  • Phone: 443-529-2745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN1040884
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR186285
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: