Basic Information
| Provider Information | |||||||||
| NPI: | 1780194175 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADLEY | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | ALLAN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22 RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | ROUNDUP | ||||||||
| State: | MT | ||||||||
| PostalCode: | 590726851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4066905157 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2800 10TH AVE N | ||||||||
| Address2: | |||||||||
| City: | BILLINGS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 591010703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062382500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2017 | ||||||||
| LastUpdateDate: | 12/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | MED-PAC-LIC-59882 | MT | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | MED-PAC-LIC-59882 | MT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.