Healthcare Provider Details

I. General information

NPI: 1013990209
Provider Name (Legal Business Name): BRADLEY DUANE FREY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 02/12/2024
Certification Date: 02/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 FULLER ST
ALEXANDRIA BAY NY
13607-1391
US

IV. Provider business mailing address

4 FULLER ST
ALEXANDRIA BAY NY
13607-1391
US

V. Phone/Fax

Practice location:
  • Phone: 315-482-1203
  • Fax: 315-482-4911
Mailing address:
  • Phone: 315-482-1277
  • Fax: 315-482-5553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number009322
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: