Healthcare Provider Details

I. General information

NPI: 1508488909
Provider Name (Legal Business Name): BRADLEY KENNETH FULLBRIGHT PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2020
Last Update Date: 10/10/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 W 4TH NORTH ST
MORRISTOWN TN
37814-3894
US

IV. Provider business mailing address

908 W 4TH NORTH ST
MORRISTOWN TN
37814-3894
US

V. Phone/Fax

Practice location:
  • Phone: 423-492-6100
  • Fax:
Mailing address:
  • Phone: 423-492-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: