Individual
ANGIE S BRADLEY
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
1505 STONEBRIDGE PARKWAY, SUITE 200, WOODSTOCK, GA 30189
(770) 926-9112
(770) 926-8240
Mailing address
300 TOWER ROAD, SUITE 200, MARIETTA, GA 30060-9403
(770) 427-5717
(770) 514-5040
Taxonomy
Speciality
Code
Description
License number
State
363AS0400X
Surgical Physician Assistant
Primary
006885
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
202I971251
MEDICARE PTAN
GA
Enumeration date
09/03/2013
Last updated
01/31/2014
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