Provider Demographics
NPI:1740694454
Name:GOETTL, BRADLEY TAIT (FNP)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:TAIT
Last Name:GOETTL
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7703 FLOYD CURL DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3901
Mailing Address - Country:US
Mailing Address - Phone:210-358-2078
Mailing Address - Fax:
Practice Address - Street 1:4502 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4402
Practice Address - Country:US
Practice Address - Phone:210-358-2078
Practice Address - Fax:210-358-1972
Is Sole Proprietor?:No
Enumeration Date:2014-06-20
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX709205146L00000X
TX766200163WE0003X
TXAP125858363LF0000X
WI6653-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX339105407Medicaid
TX339105408OtherCSHCN
TX339105408OtherCSHCN