Provider Demographics
NPI:1578183968
Name:BRADLEY, ROBERT (APRN-CNP)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 SIERRA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402-8356
Mailing Address - Country:US
Mailing Address - Phone:405-574-5715
Mailing Address - Fax:
Practice Address - Street 1:525 S SCHWARTZ AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5955
Practice Address - Country:US
Practice Address - Phone:505-609-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-26
Last Update Date:2020-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-78499-102363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS53-78499-102OtherKANSAS STATE BOARD OF NURSING