Individual
TYSON JOHN BRADLEY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
IDC
Contact information
Practice address
34800 BOB WILSON DR, SAN DIEGO, CA 92134-1098
(619) 532-6400
Mailing address
34800 BOB WILSON DR, SAN DIEGO, CA 92134-1098
Taxonomy
Speciality
Code
Description
License number
State
1710I1002X
Independent Duty Corpsman
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
B634-810-91-258-0
TRICARE
FL
Enumeration date
03/04/2019
Last updated
03/04/2019
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