MEDICARE: MR. JOSHUA BRADLEY ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	050502025	OTHER		NATABOC

General Provider Information

NPI Number	:	1225065055
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOSHUA BRADLEY ATC

Provider Business Mailing Address
First Line	:	528 HIGHWAY 180 W
Second Line	:
City	:	SILVER CITY
State	:	NM
Zip	:	88061-4400
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	528 HIGHWAY 180 W
Second Line	:
City	:	SILVER CITY
State	:	NM
Zip	:	88061-4400
Country	:	US
Telephone Number	:	575-534-1747
Fax Number	:	575-534-1748

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2006
Last Update Date	:	10/31/2015

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