Provider Demographics
NPI:1427106764
Name:BRADLEY, LISA LAVERNE (PA-C)
Entity type:Individual
Prefix:PROF
First Name:LISA
Middle Name:LAVERNE
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2823 E 7TH ST
Mailing Address - Street 2:APT. 8
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-4803
Mailing Address - Country:US
Mailing Address - Phone:562-225-0450
Mailing Address - Fax:323-291-7953
Practice Address - Street 1:3831 STOCKER ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008-5103
Practice Address - Country:US
Practice Address - Phone:323-291-6234
Practice Address - Fax:323-291-7953
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA13997363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical