Healthcare Provider Details

I. General information

NPI: 1013787357
Provider Name (Legal Business Name): BRADLEY ARTHUR GANNON IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2024
Last Update Date: 01/08/2024
Certification Date: 01/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2D RECON BN 2D MARINE DIVISION
CAMP LEJEUNE NC
28546
US

IV. Provider business mailing address

A-71 2D RECON BN 2D MARINE DIVISION
CAMP LEJEUNE NC
28546
US

V. Phone/Fax

Practice location:
  • Phone: 910-440-7703
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: