Healthcare Provider Details

I. General information

NPI: 1609593920
Provider Name (Legal Business Name): BRADLEY N DAVIS FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2022
Last Update Date: 05/04/2023
Certification Date: 04/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9584 HORIZON CIR
SPERRY OK
74073-4942
US

IV. Provider business mailing address

9584 HORIZON CIR
SPERRY OK
74073-4942
US

V. Phone/Fax

Practice location:
  • Phone: 918-576-1574
  • Fax:
Mailing address:
  • Phone: 918-576-1574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209779
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: