Provider Demographics
NPI:1235862012
Name:BRADLEY, RYAN (PA-C, CAQ-PSY)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:PA-C, CAQ-PSY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 VAN AALST BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MOORE
Mailing Address - State:GA
Mailing Address - Zip Code:31905-2102
Mailing Address - Country:US
Mailing Address - Phone:915-742-2273
Mailing Address - Fax:
Practice Address - Street 1:4315 EL SALVADOR WAY
Practice Address - Street 2:
Practice Address - City:EGLIN
Practice Address - State:FL
Practice Address - Zip Code:32542-1711
Practice Address - Country:US
Practice Address - Phone:575-386-6585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-07
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9118992363AM0700X
TX1198847363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLB224-972-93-800-0OtherSTATE DRIVERS LICENSE