Provider Demographics
NPI:1063553188
Name:HARRISON, BRADLEY KEITH (MD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:KEITH
Last Name:HARRISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2012 VANESTA PL STE 220
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66503-4101
Mailing Address - Country:US
Mailing Address - Phone:785-706-4327
Mailing Address - Fax:785-600-2225
Practice Address - Street 1:2012 VANESTA PL STE 220
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66503-4101
Practice Address - Country:US
Practice Address - Phone:857-064-3277
Practice Address - Fax:785-600-2225
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007001609207Q00000X
KS04-33249207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201093230AMedicaid
GAVAD 0000Medicare UPIN