Provider Demographics
NPI:1578126561
Name:WINE, BRADLEY W (MD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:W
Last Name:WINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6615 HILLTOP LN SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-1426
Mailing Address - Country:US
Mailing Address - Phone:316-516-6170
Mailing Address - Fax:
Practice Address - Street 1:911 MEALS AVE
Practice Address - Street 2:
Practice Address - City:VALDEZ
Practice Address - State:AK
Practice Address - Zip Code:99686-0046
Practice Address - Country:US
Practice Address - Phone:907-835-2249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-16
Last Update Date:2025-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD.MD61653822207Q00000X
AK913315207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine