Provider Demographics
NPI:1699483511
Name:ARCHER, BRADLEY
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:ARCHER
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 1:1242 S BRADEN AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74112-5333
Mailing Address - Country:US
Mailing Address - Phone:802-299-8539
Mailing Address - Fax:
Practice Address - Street 1:1242 S BRADEN AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74112-5333
Practice Address - Country:US
Practice Address - Phone:802-299-8539
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-09
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator