Provider Demographics
NPI:1043599814
Name:TENNEY, BRADFORD GIBSON (PA-C)
Entity type:Individual
Prefix:
First Name:BRADFORD
Middle Name:GIBSON
Last Name:TENNEY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18444 N 25TH AVE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-1261
Mailing Address - Country:US
Mailing Address - Phone:623-537-5600
Mailing Address - Fax:866-939-2673
Practice Address - Street 1:14520 W GRANITE VALLEY DR
Practice Address - Street 2:SUITE 210
Practice Address - City:SUN CITY WEST
Practice Address - State:AZ
Practice Address - Zip Code:85375-5855
Practice Address - Country:US
Practice Address - Phone:623-537-5600
Practice Address - Fax:866-939-2673
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-11
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4952363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ102176Medicare PIN