Provider Demographics
NPI:1912486523
Name:BRAGG, CLIFFORD J (NP)
Entity type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:J
Last Name:BRAGG
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 N STOCKTON HILL RD STE B368
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3029
Mailing Address - Country:US
Mailing Address - Phone:928-681-1234
Mailing Address - Fax:928-681-1811
Practice Address - Street 1:5225 S HIGHWAY 95 STE 6
Practice Address - Street 2:
Practice Address - City:FORT MOHAVE
Practice Address - State:AZ
Practice Address - Zip Code:86426-9111
Practice Address - Country:US
Practice Address - Phone:928-770-4560
Practice Address - Fax:928-681-1811
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLF12170429363L00000X
AZAP11644363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner