Individual
MR. RYAN BRADLEY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C, CAQ-PSY
Contact information
Practice address
4315 EL SALVADOR WAY, EGLIN, FL 32542-1711
(575) 386-6585
Mailing address
6600 VAN AALST BLVD, FORT MOORE, GA 31905-2102
(915) 742-2273
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
1198847
TX
363AM0700X
Medical Physician Assistant
Primary
9118992
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
B224-972-93-800-0
STATE DRIVERS LICENSE
FL
Enumeration date
07/07/2022
Last updated
10/04/2024
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