Healthcare Provider Details

I. General information

NPI: 1225549967
Provider Name (Legal Business Name): BRADLEY MILAM AGACNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2017
Last Update Date: 10/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1940 ALCOA HWY STE E210
KNOXVILLE TN
37920-2264
US

IV. Provider business mailing address

3413 N FOUNTAINCREST DR
KNOXVILLE TN
37918-5623
US

V. Phone/Fax

Practice location:
  • Phone: 865-524-7471
  • Fax:
Mailing address:
  • Phone: 865-322-2656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number23404
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: