=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205544236
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRAD A HERTZLER MSN, APRN, FNP-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2022
-----------------------------------------------------
Last Update Date | 12/11/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 LARKSPUR LN
-----------------------------------------------------
City | EPHRATA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17522-8402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-738-0660
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 443 NEVIN ST
-----------------------------------------------------
City | LANCASTER
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17603-3360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-314-6292
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | SP026451
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------