Provider Demographics
NPI:1053738047
Name:WILLARD, BRUCE (LAT, ATC)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:WILLARD
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10356 PARKSHORE DR
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-5511
Mailing Address - Country:US
Mailing Address - Phone:317-491-5464
Mailing Address - Fax:
Practice Address - Street 1:201 PENNSYLVANIA PARKWAY
Practice Address - Street 2:THOMAS A BRADY SPORTS MEDICINE CENTER PC
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46280
Practice Address - Country:US
Practice Address - Phone:317-491-5464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-27
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000670A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer