Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111NN1001X | Nutrition | 06258 | IA |
Y | 175F00000X | Naturopath | NA | IA |
NPI | 1518940386 |
---|---|
Provider Name | Dr. Jason Troy Bradley |
First Address | Solon, IA 52333-0399 |
Second Address | Solon, IA 52333-9457 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/11/2005 |
Last Update Date | 22/10/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0273417 | (05) | IA |
U73937 | (02) | IA |