Healthcare Provider Details

I. General information

NPI: 1174041867
Provider Name (Legal Business Name): BRADY KENT CRAFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2017
Last Update Date: 03/07/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 N COX ST STE 28
ASHEBORO NC
27203-5514
US

IV. Provider business mailing address

341 N PEACE HAVEN RD
WINSTON SALEM NC
27104-2536
US

V. Phone/Fax

Practice location:
  • Phone: 336-629-6500
  • Fax: 336-629-9500
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-13930
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: