Healthcare Provider Details

I. General information

NPI: 1740694454
Provider Name (Legal Business Name): BRADLEY TAIT GOETTL FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2014
Last Update Date: 09/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4502 MEDICAL DR
SAN ANTONIO TX
78229-4402
US

IV. Provider business mailing address

7703 FLOYD CURL DR
SAN ANTONIO TX
78229-3901
US

V. Phone/Fax

Practice location:
  • Phone: 210-358-2078
  • Fax: 210-358-1972
Mailing address:
  • Phone: 210-358-2078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146L00000X
TaxonomyParamedic
License Number709205
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number766200
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP125858
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number6653-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: