Healthcare Provider Details

I. General information

NPI: 1558895649
Provider Name (Legal Business Name): BRADLEY HOGE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2017
Last Update Date: 05/12/2020
Certification Date: 05/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 STATE ST
ERIE PA
16550-9149
US

IV. Provider business mailing address

116 BEAU DR
EDINBORO PA
16412-3202
US

V. Phone/Fax

Practice location:
  • Phone: 814-881-3654
  • Fax:
Mailing address:
  • Phone: 814-881-3654
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number116810
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: