Provider Demographics
NPI:1427145317
Name:BRADLEY, JENNIFER BLASE (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:BLASE
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13430 N MERIDIAN ST
Mailing Address - Street 2:SUITE 275
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-1405
Mailing Address - Country:US
Mailing Address - Phone:317-582-8810
Mailing Address - Fax:
Practice Address - Street 1:13430 N MERIDIAN ST
Practice Address - Street 2:SUITE 275
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-1405
Practice Address - Country:US
Practice Address - Phone:317-582-8810
Practice Address - Fax:317-582-8863
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-002534363AS0400X
IN10001216A363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN193300Medicare PIN
INM400034014Medicare PIN
Q53104Medicare UPIN
INM400074836Medicare PIN