Healthcare Provider Details

I. General information

NPI: 1467729202
Provider Name (Legal Business Name): BRADLEY DEAN BOSTIC CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2011
Last Update Date: 11/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 DAUCH DR
ASHLAND OH
44805-8845
US

IV. Provider business mailing address

626 LEXINGTON ONTARIO RD
MANSFIELD OH
44903-7563
US

V. Phone/Fax

Practice location:
  • Phone: 419-685-3369
  • Fax:
Mailing address:
  • Phone: 419-685-3369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number359240
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: