Provider Demographics
NPI:1427144757
Name:BISKUP, BRADLEY G (PA)
Entity type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:G
Last Name:BISKUP
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:263 FARMINGTON AVE
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-2212
Mailing Address - Country:US
Mailing Address - Phone:860-679-7503
Mailing Address - Fax:860-679-1610
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-0001
Practice Address - Country:US
Practice Address - Phone:860-679-3343
Practice Address - Fax:860-679-4256
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2022-09-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CT1816363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400002752Medicare PIN