Healthcare Provider Details

I. General information

NPI: 1720598972
Provider Name (Legal Business Name): BRADLEY GLEN DOLL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2017
Last Update Date: 05/02/2022
Certification Date: 05/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4920 S 30TH ST STE 103
OMAHA NE
68107-1656
US

IV. Provider business mailing address

4920 S 30TH ST STE 103
OMAHA NE
68107-1656
US

V. Phone/Fax

Practice location:
  • Phone: 402-734-4110
  • Fax: 402-734-3990
Mailing address:
  • Phone: 402-734-4110
  • Fax: 402-734-3990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2172
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPAC0942
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: