Provider Demographics
NPI:1033483458
Name:TREADWELL, BOBBY JOEL JR (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BOBBY
Middle Name:JOEL
Last Name:TREADWELL
Suffix:JR
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:4550 COBB PARKWAY NORTH NW
Mailing Address - Street 2:SUITE 309B
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-4180
Mailing Address - Country:US
Mailing Address - Phone:770-917-6795
Mailing Address - Fax:770-529-9077
Practice Address - Street 1:4550 COBB PARKWAY NORTH NW
Practice Address - Street 2:SUITE 309B
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-4180
Practice Address - Country:US
Practice Address - Phone:770-917-6795
Practice Address - Fax:770-529-9077
Is Sole Proprietor?:No
Enumeration Date:2012-03-02
Last Update Date:2015-10-06
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Provider Licenses
StateLicense IDTaxonomies
GA5730363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8101943Medicaid
NCNC5758AMedicare PIN