Provider Demographics
NPI:1386735090
Name:BENDER, BRADLEY W (MPT)
Entity type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:W
Last Name:BENDER
Suffix:
Gender:
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1005
Mailing Address - Street 2:
Mailing Address - City:PAGO PAGO
Mailing Address - State:AMERICAN SAMOA
Mailing Address - Zip Code:96799
Mailing Address - Country:UM
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 1005
Practice Address - Street 2:
Practice Address - City:PAGO PAGO
Practice Address - State:AMERICAN SAMOA
Practice Address - Zip Code:96799
Practice Address - Country:UM
Practice Address - Phone:684-699-3730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO113699174400000X
NV2668225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO483788600Medicaid
650015393OtherMEDICARE RR