Provider Demographics
NPI:1508055872
Name:BRANTLEY, AMY G E (PA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:G E
Last Name:BRANTLEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4117 N ROXBORO ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-2121
Mailing Address - Country:US
Mailing Address - Phone:919-684-8111
Mailing Address - Fax:
Practice Address - Street 1:2706 MEDICAL OFFICE PL
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-9460
Practice Address - Country:US
Practice Address - Phone:919-734-4736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-23
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01096363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant