Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | C-5957 | AR |
Y | 207QH0002X | Family Doctor - Hospice and Palliative Medicine | C-5957 | AR |
NPI | 1073579322 |
---|---|
Provider Name | Stanley Bradley |
First Address | Fayetteville, AR 72703-4618 |
Second Address | Fayetteville, AR 72703-4618 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/04/2006 |
Last Update Date | 03/05/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
103929001 | (05) | AR |
D04382 | (02) |