Healthcare Provider Details

I. General information

NPI: 1255689642
Provider Name (Legal Business Name): BRADFORD DANIEL WITHINGTON NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2012
Last Update Date: 08/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1027 N 9TH ST
MILWAUKEE WI
53233-1411
US

IV. Provider business mailing address

413 N 2ND ST UNIT 460
MILWAUKEE WI
53203-3100
US

V. Phone/Fax

Practice location:
  • Phone: 414-765-0606
  • Fax: 414-765-0226
Mailing address:
  • Phone: 920-254-6266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4938-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: