Healthcare Provider Details

I. General information

NPI: 1962662130
Provider Name (Legal Business Name): RONALD L BRADLEY PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2008
Last Update Date: 05/18/2020
Certification Date: 05/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13801 ST FRANCIS BLVD STE 200
MIDLOTHIAN VA
23114-3206
US

IV. Provider business mailing address

PO BOX 71690
RICHMOND VA
23255-1690
US

V. Phone/Fax

Practice location:
  • Phone: 804-379-2414
  • Fax: 804-379-2413
Mailing address:
  • Phone: 804-288-2830
  • Fax: 804-288-2850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110002781
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: