Provider Demographics
NPI:1063929222
Name:HARRISON, BRADLEY DAVID (CRNA)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:DAVID
Last Name:HARRISON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14441 ALPENA DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-4307
Mailing Address - Country:US
Mailing Address - Phone:586-453-8434
Mailing Address - Fax:
Practice Address - Street 1:2799 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2608
Practice Address - Country:US
Practice Address - Phone:313-916-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-09
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704281196367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered