Healthcare Provider Details

I. General information

NPI: 1417383886
Provider Name (Legal Business Name): BRADFORD MICHAEL CHANEY I FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2013
Last Update Date: 09/22/2021
Certification Date: 09/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 HICKORY ST NW STE 303
ALBANY OR
97321-1700
US

IV. Provider business mailing address

PO BOX 1188
CORVALLIS OR
97339-1188
US

V. Phone/Fax

Practice location:
  • Phone: 541-812-5275
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number60263557
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number098003053RN
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201501044NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: