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General NPI Number Information
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NPI Number | 1639482573
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Entity Type | Individual
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Provider Name | SHAWN RICHARD BRADY PA-C
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Gender | Male
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Dates
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Enumeration Date | 07/21/2010
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Last Update Date | 07/21/2010
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Provider Practice Location Address
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Address Line | 201 CHESTNUT HILL RD
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City | STAFFORD SPRINGS
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State | CT
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Zip | 06076-4005
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Country | US
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Telephone | 860-684-8126
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Fax |
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Provider Business Mailing Address
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Address Line | 72 KINGFISHER CIR
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City | SOUTH WINDSOR
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State | CT
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Zip | 06074-4307
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 2417
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License Number State | CT
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