Provider Demographics
NPI:1104951920
Name:BRADLEY, MARTHA
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 35 BOX 5475A
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-8801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:HC 35 BOX 5475A
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-8801
Practice Address - Country:US
Practice Address - Phone:907-258-5665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK723449251B00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCM5665Medicare UPIN
AKCMG678Medicare UPIN