Healthcare Provider Details

I. General information

NPI: 1508105305
Provider Name (Legal Business Name): BRADLEY ELLIOTT STEVENS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2013
Last Update Date: 02/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 N CENTER ST SUITE 201
HICKORY NC
28601-5057
US

IV. Provider business mailing address

415 N CENTER ST SUITE 201
HICKORY NC
28601-5057
US

V. Phone/Fax

Practice location:
  • Phone: 828-327-8105
  • Fax: 828-327-4245
Mailing address:
  • Phone: 828-327-8105
  • Fax: 828-327-4245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number225005
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: