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NPI Code Detail

MEDICARE: LARRY ALLAN BRADLEY PA-C

MEDICARE: LARRY ALLAN BRADLEY PA-C
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
1363A00000XPhysician AssistantMED-PAC-LIC-59882MT
2363AM0700XMedical Physician AssistantMED-PAC-LIC-59882MT

General Provider Information

NPI Number : 1780194175
Entity Type Code : Individual
Provider Name (Legal Business Name) : LARRY ALLAN BRADLEY PA-C
Provider Business Mailing Address
First Line : 22 RIDGE RD
Second Line :
City : ROUNDUP
State : MT
Zip : 59072-6851
Country : US
Telephone Number : 406-690-5157
Fax Number :
Provider Business Practice Location Address
First Line : 2800 10TH AVE N
Second Line :
City : BILLINGS
State : MT
Zip : 59101-0703
Country : US
Telephone Number : 406-238-2500
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/11/2017
Last Update Date : 12/14/2021

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