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General NPI Number Information
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NPI Number | 1740463876
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Entity Type | Individual
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Provider Name | BRADLEY JOHN ESPESETH NP-C
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Gender | Male
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Dates
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Enumeration Date | 12/12/2007
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Last Update Date | 11/06/2018
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Provider Practice Location Address
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Address Line | 516 E NIZHONI BLVD
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City | GALLUP
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State | NM
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Zip | 87301-5748
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Country | US
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Telephone | 505-722-1000
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 130
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City | SAN FIDEL
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State | NM
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Zip | 87049-0130
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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 | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | R60407
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | CNP-03469
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License Number State | NM
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