Provider Demographics
NPI:1093011710
Name:BULLOCK, BRADY TIMOTHY (PA-C)
Entity Type:Individual
Prefix:
First Name:BRADY
Middle Name:TIMOTHY
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 360
Mailing Address - Street 2:
Mailing Address - City:SYLVA
Mailing Address - State:NC
Mailing Address - Zip Code:28779-0360
Mailing Address - Country:US
Mailing Address - Phone:828-693-3344
Mailing Address - Fax:828-692-2487
Practice Address - Street 1:317 N KING ST STE A
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28792-4349
Practice Address - Country:US
Practice Address - Phone:828-693-3344
Practice Address - Fax:828-692-2487
Is Sole Proprietor?:No
Enumeration Date:2011-01-27
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003508363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant