=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700259181
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH ALEXANDRA BRADBURY PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2015
-----------------------------------------------------
Last Update Date | 12/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4140 JADE ST STE 100
-----------------------------------------------------
City | CAPITOLA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95010-3940
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-475-4024
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 31396
-----------------------------------------------------
City | WALNUT CREEK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94598-8396
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 53014
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------