Provider Demographics
NPI:1285246041
Name:NIELSON, BRAD
Entity type:Individual
Prefix:
First Name:BRAD
Middle Name:
Last Name:NIELSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1930 N HAIDEN LN
Mailing Address - Street 2:
Mailing Address - City:WILLCOX
Mailing Address - State:AZ
Mailing Address - Zip Code:85643-3396
Mailing Address - Country:US
Mailing Address - Phone:480-335-1862
Mailing Address - Fax:
Practice Address - Street 1:1930 N HAIDEN LN
Practice Address - Street 2:
Practice Address - City:WILLCOX
Practice Address - State:AZ
Practice Address - Zip Code:85643-3396
Practice Address - Country:US
Practice Address - Phone:480-335-1862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-21
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN211989163W00000X
AZ293673367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse