Provider Demographics
NPI:1093417339
Name:OGLESBY, BRAD ALAN (APRN)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:ALAN
Last Name:OGLESBY
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 OAKWOOD TRL
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30252-8011
Mailing Address - Country:US
Mailing Address - Phone:678-591-6798
Mailing Address - Fax:
Practice Address - Street 1:126 OAKWOOD TRL
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30252-8011
Practice Address - Country:US
Practice Address - Phone:678-591-6798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN211256363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health