Provider Demographics
NPI:1437504867
Name:BRADAC, KRISTEN MAY (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MAY
Last Name:BRADAC
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:MAY
Other - Last Name:HESSELBACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:842 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7134
Mailing Address - Country:US
Mailing Address - Phone:720-218-7427
Mailing Address - Fax:
Practice Address - Street 1:842 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7134
Practice Address - Country:US
Practice Address - Phone:720-218-7427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-04
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
ORPA183419363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500734596Medicaid