Healthcare Provider Details

I. General information

NPI: 1467868281
Provider Name (Legal Business Name): BRADLEY J MCKERNAN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2014
Last Update Date: 12/06/2021
Certification Date: 12/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 HIGH ST
BUFFALO NY
14203-1149
US

IV. Provider business mailing address

425 ESSJAY RD STE 170
WILLIAMSVILLE NY
14221-8235
US

V. Phone/Fax

Practice location:
  • Phone: 716-630-1000
  • Fax: 716-630-1348
Mailing address:
  • Phone: 716-630-1219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number017595
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: