Provider Demographics
NPI:1679568349
Name:BRADLEY, DARIN WALTER STANLEY (PA-C)
Entity type:Individual
Prefix:
First Name:DARIN
Middle Name:WALTER STANLEY
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 DAVIT LN
Mailing Address - Street 2:
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28560-7204
Mailing Address - Country:US
Mailing Address - Phone:802-989-1305
Mailing Address - Fax:
Practice Address - Street 1:2002 S GLENBURNIE RD STE 100
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-5229
Practice Address - Country:US
Practice Address - Phone:252-631-5188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055-0030633363AM0700X
NC0010-11814363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTAP1729Medicare ID - Type Unspecified
P41429Medicare UPIN