Healthcare Provider Details

I. General information

NPI: 1013785955
Provider Name (Legal Business Name): ABIGAIL BRADLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2023
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 S 13TH ST
MOUNT VERNON WA
98274-4107
US

IV. Provider business mailing address

1400 E KINCAID ST
MOUNT VERNON WA
98274-4127
US

V. Phone/Fax

Practice location:
  • Phone: 360-814-2663
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.PA.61518189
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: