Provider Demographics
NPI:1083168793
Name:DAVIS, BRADLEY T (NP)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:T
Last Name:DAVIS
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 1:910 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:CORDELE
Mailing Address - State:GA
Mailing Address - Zip Code:31015-3254
Mailing Address - Country:US
Mailing Address - Phone:229-276-2286
Mailing Address - Fax:229-276-2289
Practice Address - Street 1:910 N 5TH ST
Practice Address - Street 2:
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015
Practice Address - Country:US
Practice Address - Phone:229-276-2286
Practice Address - Fax:229-276-2289
Is Sole Proprietor?:No
Enumeration Date:2016-08-10
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN191357363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology