Healthcare Provider Details

I. General information

NPI: 1750487823
Provider Name (Legal Business Name): BRADLEY ALLEN HISER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 12/13/2019
Certification Date: 12/13/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 QUAIL CREEK DR
AMARILLO TX
79124
US

IV. Provider business mailing address

705 QUAIL CREEK DR
AMARILLO TX
79124
US

V. Phone/Fax

Practice location:
  • Phone: 806-353-6400
  • Fax: 806-358-2662
Mailing address:
  • Phone: 806-353-6400
  • Fax: 806-358-2662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number2012008248
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberR7022
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: