Provider Demographics
NPI:1053190892
Name:WEITLAUF, BRADLEY JOSEPH
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:JOSEPH
Last Name:WEITLAUF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 SUSAN LN
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-5526
Mailing Address - Country:US
Mailing Address - Phone:865-304-3791
Mailing Address - Fax:
Practice Address - Street 1:160 SUSAN LN
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-5526
Practice Address - Country:US
Practice Address - Phone:865-304-3791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide