=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558762062
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRADLEY ELIAS SNYDER NP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2014
-----------------------------------------------------
Last Update Date | 03/04/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 655 W LOMBARD ST
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21201-1512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-529-2745
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3512 POOLE ST
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21211-2327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-529-2745
-----------------------------------------------------
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 | RN1040884
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | R186285
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------