Provider Demographics
NPI:1265490098
Name:PAGE, BRADLEY DANIEL (PA)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:DANIEL
Last Name:PAGE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:11608 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:HOBOKEN
Mailing Address - State:GA
Mailing Address - Zip Code:31542-2106
Mailing Address - Country:US
Mailing Address - Phone:912-288-3417
Mailing Address - Fax:912-283-8204
Practice Address - Street 1:2005 PIONEER ST STE C
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-6205
Practice Address - Country:US
Practice Address - Phone:912-490-7777
Practice Address - Fax:912-490-7778
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2020-02-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA4755207Q00000X
GA004775363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAQ70439Medicare UPIN
GA97WCJHLMedicare PIN