Healthcare Provider Details

I. General information

NPI: 1952706103
Provider Name (Legal Business Name): BRADLEY EDWARD SMITH PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2014
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34509 9TH AVE S STE 204
FEDERAL WAY WA
98003-8708
US

IV. Provider business mailing address

34509 9TH AVE S STE 204
FEDERAL WAY WA
98003-8708
US

V. Phone/Fax

Practice location:
  • Phone: 253-835-5510
  • Fax: 253-835-5511
Mailing address:
  • Phone: 253-835-5510
  • Fax: 253-835-5511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60514442
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA60514442
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: